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This article provides an overview of the current methods of diagnosis and treatment of patients with vertigo, dizziness, or imbalance, as well as an analysis of ongoing problems besetting the field of neuro-otology. Aims and challenges are also described with the hope of stimulating basic and clinical research on these very frequent symptoms.
Vertigo and dizziness are among the most frequent symptoms that patients experience at some time in their lives. With a lifetime prevalence of about 30% and an annual incidence that increases with age, vertigo and dizziness will become even more important in the future. Despite this high prevalence and burden of disease, considerable challenges remain.
In brief our growing knowledge of the anatomy and physiology of the vestibular and related ocular motor systems, as well as basic and clinical research must still overcome a number of shortcomings and limitations to improve diagnosis, develop new diagnostic criteria, and better understand the pathophysiology of these disorders. Hopefully, new treatment strategies and state-of-the-art prospective clinical trials will improve the quality of life and functioning in patients with vertigo and dizziness.
First, we must increase worldwide awareness of the impact of vertigo and dizziness. While acute vertigo and dizziness may be the first sign of severe neurological disorders such as brainstem or cerebellar ischemia, chronic vertigo, dizziness, and balance disorders – in particular, if patients are not aware of their cause and are not adequately treated – have a considerable socio-economic impact.
Second, it is very important to improve the cooperation between ENT, neurology, neuro-ophthalmology, ophthalmology, and psychiatry, because many patients fall between these different specialties. Such cooperation requires the establishment of specialized interdisciplinary centers, in which ENT specialists, neurologists, ophthalmologists, psychiatrists, psychologists, cardiologists, radiologists, and neuroradiologists closely collaborate and examine patients together as a team. An example of such a center is the newly established Integrated Center for Research and Treatment of Vertigo, Dizziness and Ocular Motor Disorders (IFBLMU) at the University of Munich. The German Ministry of Research and Education will fund this center with 5 million Euros per year for 5–10 years. This novel patient-centered approach will allow the establishment of new paradigms to overcome the boundaries between these disciplines and thus have an enduring effect.
Third, only such an interdisciplinary approach will increase the knowledge and improve the skills of medical students and even physicians experienced in this field. Interdisciplinary thinking will be imperative in addition to a specialized curriculum covering vertigo, dizziness, imbalance, ocular motor, and gait disorders. It would suffice to have just one or two such centers per country. This approach would also have a snowballing effect leading to the creation of special examinations and certificate of qualifications.
Fourth, diagnostic criteria for some of the vestibular and ocular motor disorders have to be better defined and then internationally recognized. The Bárány Society therefore recently proposed an initiative, led by Dr. Alexandre Bisdorff, to establish committees that would formulate such criteria for the different forms of vertigo and dizziness. This has implications for clinical practice as well as for further clinical trials.
Fifth, multicenter, multinational prospective randomized placebo-controlled trials are urgently needed for a number of these disorders. Such studies should also measure the quality of life and functioning whenever possible. Examples are:
Further, histopathological post-mortem studies will require the establishment of brain banks on frequent disorders like bilateral vestibulopathy, Menière's disease, downbeat nystagmus, and episodic ataxia, to further enhance our knowledge about the histological changes and to differentiate possibly different forms. Finally, vestibular prostheses are being developed for patients with a complete bilateral vestibular failure but they still have to be implemented in clinical use.
The long-term goals of these measures should be
Looking back at the developments in the field over the last 20 years, we are highly optimistic that most of these goals will be reached within the next 20 years.
Submission of manuscripts dealing with the above-mentioned aspects will be very welcomed at Frontiers in Neuro-otology.