Research in Vestibular Science

Review Articles

Recent advances in diagnostic and therapeutic strategies for management of dizzy patients in Japan: Noriaki Takeda; Res Vestib Sci. 2025;24(1):1-9. Published online March 14, 2025; DOI: https://doi.org/10.21790/rvs.2025.001

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Abstract PDF: The present review summarized the recent advances in diagnostic and therapeutic strategies for management of dizzy patients in Japan. Standardization of diagnosis, examination, and treatment of vestibular disorders and nationwide epidemiological surveys of vestibular disorders are high-priority projects of Japan Society for Equilibrium Research (JSER). JSER published clinical practice guidelines for Ménière’s disease, delayed endolymphatic hydrops, benign paroxysmal positional vertigo, vestibular neuritis, vestibular test battery, and vestibular rehabilitation. JSER published a video library of vestibular testing and nystagmus and abnormal eye movements. JSER performed nationwide surveys of Ménière’s disease, delayed endolymphatic hydrops, and bilateral vestibulopathy. Visualization of endolymphatic hydrops in gadolinium-enhanced magnetic resonance imaging (MRI) was developed in Japan. MRI of endolymphatic hydrops becomes an indispensable tool to diagnose Ménière’s disease. The new surgical procedure of endolymphatic sac surgery with steroid instillation and middle ear pressure therapy with a Japanese device become new therapeutic strategies for intractable Ménière’s disease in Japan. Neural and pharmacological mechanisms of static vestibular compensation were revealed in Japan. Diazepam accelerates the initial process of static vestibular compensation and short-term administration with diazepam is recommended for the treatment of acute vertigo in patients with unilateral vestibulopathy. Betahistine accelerates the late process of static vestibular compensation and long-term administration with betahistine is recommended for the treatment of subacute vertigo in patients with unilateral vestibulopathy. Vestibular rehabilitation is effective in developing dynamic vestibular compensation and beneficial for improving chronic dizziness in patients with unilateral vestibulopathy. Vestibular rehabilitation with a Japanese vestibular substitution device is a promising strategy for chronic dizziness in patients with unilateral vestibulopathy.

Clinical application of virtual reality for vestibular rehabilitation: Sung Kwang Hong; Res Vestib Sci. 2024;23(4):124-131. Published online December 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.019

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Abstract PDF: Virtual reality has emerged as a promising tool in vestibular rehabilitation therapy (VRT), offering immersive and interactive environments that enhance patient engagement and adherence to therapy. Its potential lies in delivering controlled, customizable exercise protocols that simulate real-world challenges in a safe, monitored environment. This allows healthcare providers to tailor exercises based on gaze stabilization, vestibulo-ocular reflex training, and balance training, according to a patient’s specific complaints, symptoms, and progress. While cybersickness is a potential concern with virtual reality interventions, patients with vestibular loss are generally less susceptible to the visual-vestibular mismatch that often causes motion sickness. Studies have shown that side effects, such as nausea or discomfort from cybersickness, are minimal for most patients undergoing virtual reality-based VRT. Despite these promising results, further research is needed to fully validate the effectiveness of virtual reality interventions in VRT. This article will explore the current status and future potential of virtual reality in VRT, including considerations for its clinical application and areas for future research.

Review

Vestibular Migraine: A Recent Update on Diagnosis and Treatment: Young Seo Kim, Hak Seung Lee; Res Vestib Sci. 2022;21(3):67-74. Published online September 15, 2022; DOI: https://doi.org/10.21790/rvs.2022.21.3.67

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Abstract PDF: Vestibular migraine (VM) is a variant of migraine resulting in vestibular symptoms in addition to symptoms typical of migraine. However, without a biomarker or a complete understanding of the pathophysiology, VM remains underrecognized and underdiagnosed. Therefore, the diagnosis of VM is still challenging. Meanwhile, VM should be clearly differentiated from other similar diseases. Here, we highlight these challenges, discuss common vestibular symptoms and clinical presentations in VM, and review the current aspects of its clinical diagnosis and evaluation. The concepts related to the treatment of VM are also discussed.

Case Report

Ocular Flutter in Parainfectious Meningoencephalitis: A Case Report: In-Ho Yoon, Seung-Hoon Yun, Bong-Hui Kang; Res Vestib Sci. 2021;20(3):113-117. Published online September 15, 2021; DOI: https://doi.org/10.21790/rvs.2021.20.3.113

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Abstract PDF Supplementary Material: Ocular flutter is a rare, horizontal eye movement disorder characterized by intermittent bursts of conjugate horizontal saccades without intersaccadic intervals. It can occur in various clinical conditions such as metabolic dysfunction, infection and paraneoplastic syndrome. Herein, a 50-year-old male showed ocular flutter in parainfectious meningoencephalitis and immunoglobulin therapy led to an improvement of symptoms. This case can improve the understanding of the pathological mechanisms of ocular flutter.

Reviews

Review for Update on Vestibular Rehabilitation: Eun Ju Jeon; Res Vestib Sci. 2016;15(2):31-38. Published online June 15, 2016

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Abstract PDF: Vestibular rehabilitation (VR) is valuable tool to manage balance problem in various kinds of diseases. Over the last decades, numerous studies on the effect of VR have been reported. Recently, systematic analysis integrating the individual studies have been tried and the results suggest that VR is safe and effective management for the acute/chronic and unilateral/bilateral peripheral vestibular dysfunction, and also for the elderly people. VR relieves dizziness and improves gaze stability, postural stability, parameters of gait, and activities of daily living. Currently released "Clinical practice guideline of VR on peripheral vestibular dysfunction" support and assist the use of VR in clinical field. More research is needed to develop uniform evaluation tool to measure the symptomatic and functional status of the patients and individualized efficient rehabilitation programs. It is expected that device for VR incorporating new technologies such as virtual reality will be developed in near future.

Vestibular Rehabilitation in Central Dizziness: Byung In Han, Pan Woo Ko, Ho Won Lee, Hyun Ah Kim, Hyung Lee; Res Vestib Sci. 2015;14(4):97-100.

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Abstract PDF: Vestibular rehabilitation therapy (VRT) is an exercise-based treatment program designed to promote vestibular adaptive and compensatory mechanisms already existing in the human brain. Although the evidence is sparse for improvement in subjects with central vestibular dysfunction following VRT, it improves postural stability in cerebellar diseases and reduces subjective complaints and fall risk in Parkinson disease. Possible mechanisms of recovery after central nervous system lesions may include neural sprouting, vicarious functions, functional reorganization, substitution, and plasticity. VRT regimens for patients with central causes should include balance and gait training, general strengthening and flexibility exercises, utilization of somatosensory and vision and utilization of alternate motor control strategies. VRT would be an option to relieve the symptoms of the many patients who have central dizziness.

Surgical Treatments of Benign Paroxysmal Positional Vertigo: Shin Hye Kim, Hyun Seok Choi, Ja Won Koo; Res Vestib Sci. 2014;13(2):29-33.

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Abstract PDF: Benign paroxysmal positional vertigo (BPPV) is the most frequent vestibular disorder. Although it is easily cured with canal repositioning maneuvers for the majority of patients, it can be disabling in rare cases. For these patients, surgical treatments may be proposed. The aim of this article is to discuss their indication in intractable BPPV and review the surgical treatments used, the reported cases in the literature. All the articles from 1972 to 2013 that discussed specific surgical treatments in BPPV were reviewed. Many of them reported cases of operated patients and described original techniques. Some others are studies that discussed the three techniques used: singular neurectomy, posterior semicircular canal occlusion and intratympanic injection of gentamicin. Singular neurectomy and posterior semicircular canal occlusion are the two specific techniques used in intractable BPPV. A very small population of patients requires surgical treatments of BPPV. These procedures are difficult and risk compromising hearing. The intratympanic injection of gentamicin can be useful procedure in BPPV associated with Meniere disease. The surgical treatments of BPPV appear to be limited to exceptional cases. When good examination and appropriate treatment fail to cure patients with intractable BPPV, central positional vertigo should be ruled out before irreversible surgical procedures.

Original Articles

Efficacy of Oral Prostaglandin I2 in Patients with Chronic Nonspecific Vertigo: Ji Won Kim, Hyun Woo Lim, Yun Suk An, Seung Hyo Choi, Hong Ju Park, Jong Woo Chung; Res Vestib Sci. 2011;10(4):115-120.

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Abstract PDF: Background and Objectives: The aim of this study is to evaluate the efficacy of prostaglandin I2 (PGI2) in the patients with chronic nonspecific vertigo using questionnaires of dizziness handicap inventory (DHI) and vertigo symptom scale (VSS). Materials and Methods: Forty two patients with chronic nonspecific vertigo from May to December 2010 were enrolled in this study. We administered Berast (synthetic PGI2, beraprost sodium) 2 tablets (0.04 mg) twice a day to patients. Before and after 2, 4 weeks the end of administration patients underwent DHI and VSS for evaluation of state of the vertigo. Results: Twenty four of 42 patients completed this clinical trial. Mean DHI scale score decreased significantly from 23.00 (±21.75) to 17.75 (±19.78) (p=0.004). All DHI subscales, physical, functional, and emotional factors, decreased after treatment of prostaglandin I2. VSS scale also showed significant decrease from 3.63 (±2.55) to 2.50 (±2.95) (p=0.044). Conclusion: Prostaglandin I2 may be one of the treatments to improve symptoms in the patient s with chronic nonspecific vertigo.

Clinical Features and Treatment Pattern of Migrainous Vertigo in Korea: A Nationwide Prospective Multicenter Study: Seong Ki Ahn, Kyusik Kang, Ja Won Koo, Kyu Sung Kim, Beom Gyu Kim, Byung Kun Kim, Ji Soo Kim, Kyoung Ho Park, Shi Nae Park, Eun Ho Park, Hong Ju Park, Jae Yong Byun, Myung Whan Suh, Ki Bum Sung, Sun Young Oh, Chung Ku Rhee, Tae Kyeong Lee, Seong Hae Jeong, Won Ho Chung, Chang Il Cha, Sung Won Chae, Eui Kyung Goh; Res Vestib Sci. 2009;8(2):122-131.

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Abstract PDF: Background and Objectives It is being increasing recognized that the morbidities of migraine and balance disorders are interrelated. In fact, migrainous vertigo (MV) is one of frequent causes of recurrent vertigo in patients presenting to specialized dizziness clinics. Nevertheless, not many studies have reported clinical manifestations and treatment. Therefore, the aim of study was designed to assess clinical features and treatment patterns by a nationwide multicenter study. Materials and Methods Patients between 9 and 74 years of age who visited 17 Korean tertiary referral centers and 1 clinic from February to March 2009 were investigated using two forms of questionnaires. Results Overall, 318 patients with MV were enrolled. MV was responsible for ~8.45% of visits to the specialized dizziness clinics. One hundred seventy-five of these patients had definite MV and were included in assessing the clinical features. Vertigo characteristics of patients with definite MV were various. Vertigo was regularly as-sociated with headache in 87% of the patients. The duration of vertigo ranged from seconds to days. For the treatment patterns, an acute and prophylactic therapies were carried in most clinics. There were no differences in either acute or prophylactic therapies between department of neurology and otorhinolaryngology. Conclusions The results of this study suggest that MV the clinical features of MV also varies in Korea. In addition, most clinics provide similar patterns of practice in treatment for MV. The syndrome of MV deserves further research activity as it is relatively common and clinically relevant.

Multicenter study on the treatment pattern of Ménière’s disease in Korea: Sung Kwang Hong, Eui Kyung Koh, Kyu Sung Kim, Kyoung Ho Park, Hong Ju Park, Seong Ki Ahn, Joong Ho Ahn, Won Sang Lee, Gi Jung Im, Jae Yun Jung, Won Ho Chung, Gyu Cheol Han, Sung Won Chae, Ja Won Koo; J Korean Bal Soc. 2008;7(2):174-181.

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Abstract PDF: Background and Objectives: It is hard to determine the efficacy of several treatment options of Ménière’s disease since dynamic course of the disease and diverse rate of recurrence. Few modalities are regarded as ‘effective’ in the viewpoint of evidence based medicine. Study was conducted to know the current status of treatment options for Ménière’s disease. Materials and Methods: A multicenter survey was conducted using questionnaires to collect information on current status of treatment patterns in Ménière’s disease. The questionnaire answered by neurotologic surgeons working at 12 institutes in Korea was analyzed. Results: Low salt diet was always instructed to their patients, but 8 out of 12 responders (67%) did not emphasis on the amount of dietary salt. Duration of pharmacotherapy was ranged from 3 to 12 months. Intratympanic steroid injection was performed in 8 institutes (67%). Every institute agreed on the role of intratympanic gentamicin application. Treatment options for intractable patients were asked. Endolymphatic sac surgery, intratympanic steroid, Meniette device and intratympanic aminoglycoside injection were answered in patients who hope to preserve residual hearing. On the contrary, in patients without serviceable hearing, intratympanic jnjection of aminoglycosides (9/12, 75%) dominated as the next treatment option. Conclusions: Most institutes provide similar patterns of practice in medical treatment. The application of intratympanic aminoglycoside is also agreed in intractable patients without serviceable hearing. However, thoughts about the role and detailed methods of the surgical and adjunctive treatment options were not agreed, especially in intractable patients with good hearing. Further clinical studies and discussions would be necessary to provide consensus for the best treatment of Ménière’s disease in Korea. Key words : Ménière’s disease, Pharmacotherapy, Surgery, Aminoglycosides

Recurrent Vestibulopathy: Clinical Characteristics and Efficacy of Combination Therapy: Shi Nae Park, Kyoung Ho Park, Dong Jae Im, Jong Hoon Kim, Jun Yop Kim, Sang Won Yeo; J Korean Bal Soc. 2006;5(2):262-268.

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Abstract PDF: Background
and Objectives: Recurrent vestibulopathy is defined a disease characterized by more than a single episode of vertigo of duration characteristic of endolymphatic hydrops but without auditory or clinical neurological symptoms or signs. To investigate the clinical characteristics and the efficacy of combination therapy, we analyzed the clinical records of the patients diagnosed as recurrent vestibulopathy. Materials and Method: Clinical records of sixty four patients diagnosed as recurrent vestibulopathy were retrospectively reviewed. The data on age, sex distribution, natural history, family history of recurrent vestibulopathy, concurrent headache, caloric response was analyzed. The efficacy of combination therapy for vertigo control in the patients with a minimum 24-month follow-up was also evaluated.
Results
Mean onset age of recurrent vestibulopathy was 43 years and there was a female preponderance. Concurrent headache and elevated SP/AP ratio in electrocochleogram was frequently observed in these patients. After the combination medical therapy, patients with severe recurrent vestibulopathy showed significant decrease in the number of vertigo spells with 37.5% of complete control of vertigo.
Conclusion
As a distinctive clinical disorder with unknown cause, recurrent vestibulopathy should be always considered to the patients complaining recurrent episodic vertigo. Combination therapy individualized to the symptoms and signs of the patients with recurrent vestibulopathy might be effective in reducing the frequency of vertigo attacks. Further case-control studies with large population should be necessary. Key Words : Recurrent vestibulopathy, Therapy ∙

The Effectiveness of Physical Therapy for the Horizontal Canal Cupulolithiasis: Byung Kun Kim, Hee Jun Bae, Ja Seong Koo, Oh Hyun Kwon, Jong Moo Park; J Korean Bal Soc. 2005;4(2):219-224.

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Abstract PDF: Background
and Objectives: Recently many reports suggest the horizontal canal benign paroxysmal positional vertigo (h-BPPV) is not rare. However there have been few reports on physical therapy for horizontal canal cupulolithiasis, while horizontal canal canalithiasis has a relatively well defined and effective therapy. To evaluate the efficacy of different methods of treating horizontal canal cupulolithiasis, we conducted prospective study. Materials and Method: We enrolled 104 consecutive patients who were diagnosed with h-BPPV. During that period, patients with posterior canal BPPV numbered 112. Patients with h-BPPV were diagnosed when lateral head rotation in the supine position resulted in geotropic or apogeotropic bilateral horizontal nystagmus. In patients presenting with apogeotropic variant (n=40), following maneuvers was performed sequentially. First of all, we performed head shaking and applied vibrator to the mastoid bone to detach otolith from cupula. If they failed to detach otolith from cupula, we performed barbecue rotation and forced prolonged position (FPP). The treatment outcome was considered as responsive when, immediately after each physical therapy, nystagmus shifted from apogeotropic to geotropic or no nystagmus was elicited by provocation test and symptoms of positional vertigo abated.
Results
There were 27 women and 13 men from ages 30 to 80 (mean 55) years. The average duration of symptoms before intervention was 0 to 12 (mean 0.6) days. In 4 cases, symptoms resolved spontaneously after provocation test. Of the 36 patients treated with headshaking, 6 were responsive. Of the 30 patients treated with vibrator after failure of head shaking, only 1 were responsive. In the barbecue rotation, none obtained relief after barbecue rotation. Of the 9 patients treated with FPP after failure of the barbecue rotation, 4 were symptom free after FPP. Twenty five patients, including 5 non-responders with FPP, underwent no more rehabilitation maneuver. In most of cases (n=24), horizontal canal cupulolithiasis resolved spontaneously within a week.
Conclusion
The direct effectiveness of physical therapy for horizontal canal cupulolithiasis is largely unsatisfactory. However, in many cases, horizontal canal cupulolithiasis resolved spontaneously in a few days.

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