1. health and fitness
2. disease

Auris Nasus Larynx 36 (2009) 30–35
www.elsevier.com/locate/anl
A clinical epidemiological study in 2169 patients with vertigo
Min Yin, Kazuo Ishikawa *, Weng Hoe Wong, Yutaka Shibata
Division of Otorhinolaryngology, Head and Neck Surgery, Department of Sensory Medicine,
Akita University School of Medicine, Hondo 1-1-1, Akita 010-8543, Japan
Received 27 March 2007; accepted 5 March 2008
Available online 16 May 2008
Abstract
Objective: To investigate the clinical epidemiological characteristics of vertigo.
Methods: Retrospective study on 2169 patients with vertigo (male 883, female 1286, 7–90 years old) of the past 20 years.
Results: More than 50 kinds of causative diseases were recognized. Peripheral, central, and unclassified vertigo took up 33.8, 17.2 and 26.8%
of patients, respectively, while vertigo of unknown origin was around 22.2%. Vertigo patients increased according to age and reached its peak
in the 1960s among all three categories. Although female patients were seemingly overwhelmed the male, no significant difference in the
incidence rate was recognized in two genders. Only 2.2% (48 cases) of the total vertigo patients were children, while elders occupied 30.0%
(650 cases). Compared to younger patients, the elderly have a high tendency of suffering central vertigo.
Conclusion: Vertigo attacks patients in all age spans, with various causative diseases.
# 2008 Elsevier Ireland Ltd. All rights reserved.
Keywords: Vertigo; Central; Peripheral; Causative disease
1. Introduction
Vertigo is a very common complaint in clinical practice. The
epidemiological knowledge on vertigo is still limited, whether
on its prevalence or incidence character. Present studies might
be divided into two aspects: population study and clinical study.
Both of them have advantages and disadvantages.
Some population studies were carried out by means of
questionnaire survey mainly in a defined region and people
[1–3], which could be expected to reveal the prevalence of
vertigo or dizziness. However, dizziness or vertigo is a nonspecific symptom. In many cases, diagnosis must be based
on clinical evidences, despite of accurate expression of
vertigo or dizziness, together with the detailed attacking
story that might lead to a diagnosis to some extent. A
definitive cause may not be confirmed by means of a
questionnaire only. As a result, the population study may
be based on a relatively correct diagnosis, but it could
* Corresponding author. Tel.: +81 18 884 6171; fax: +81 18 836 2622.
E-mail address: [email protected] (K. Ishikawa).
not furthermore tell the epidemiological character of the
causative disease.
Clinical studies were usually performed in selected patient
groups [4–6]. Other studies were also focused on children and
elders [7,8]. On this occasion, the general prevalent
characteristic of the diseases could not be suggested, as it
is not conducted in a certain population. However, a relative
definitive diagnosis could be available, and the incidence of
specific vertigo could possibly be discussed. As vertigo or
dizziness is a clinical symptom with multiple causative
diseases, a selected patient group with a small population will
lead to quite different results as suggested in previous studies
[4–6]. Due to the variety of causative diseases of vertigo, a
certain number of patients should be necessary to describe its
character for clinical study.
In order to investigate the clinical characteristics of the
incidence of vertigo and its causative disease, our study was
specially designed in a university hospital that is a core
hospital in the district. We retrospectively reviewed 2169
patients with vertigo in this study. We hope this will become
a reference for clinical work.
0385-8146/$ – see front matter # 2008 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.anl.2008.03.006
M. Yin et al. / Auris Nasus Larynx 36 (2009) 30–35
2. Patients and methods
This study included all patients who complained of
vertigo and consulted our department in the past 20 years.
The total subjects were 2169 (male 883, female 1286) and
aged between 7 and 90 years.
All patients complaining of vertigo were examined by
doctors (co-authors of this paper) specialized in neurootology. A clinical history was first taken carefully for each
patient precisely about the attack and development of
vertigo either rotatory or not, duration, intensity, accompanied symptoms, frequency, possible causes, and so on.
Neuro-otological examinations were performed for each
patient including otoscopy, pure-tone/speech audiometry,
rentorgenmetry of Stenver’s and Schueller’s position,
Schellong test, nystagmus test (spontaneous and gaze
nystagmus, positional and positioning nystagmus test,
by CCD camera), and standard electronystagmography
(including spontaneous nystagmus, saccade, eye tracking,
optokinetic nystagmus, optokinetic after nystagmus,
caloric and visual suppression test). Further audiological
examinations (self-recording audiometery, speech discrimination, auditory brain stem response, evoked otoacoustic emission, etc.), stabilometric and locomotion tests, and
CT/MRI scan would be applied when necessary. Patients
were properly treated and followed up on at least for 4
weeks.
A final and standard diagnosis of each case would be
made under a fine discussion with a neuro-otology expert
(the professor of our department) in a weekly held vertigo
conference, and databased. Examinations and diagnoses
were based on the diagnostic criteria of the Japan Society for
Equilibrium Research [9].
In this study, gender, age, diagnosis and causative disease
of the vertigo patients were summarized based upon the
database of our vertigo conference. The vertigo was
distinguished into four categories: peripheral, central,
unclassified (vertigo of known causes but neither peripheral
nor central) and unknown (vertigo with unknown origin). In
occasion of the return patients, only their first diagnosis was
counted (the return patients with different causes were
excluded). Cochran armitage trend test and x2-test were
applied for statistical analysis.
3. Results
3.1. The causative diseases of vertigo
The constituent of peripheral, central, and unclassified
vertigo were 33.8%, 17.2% and 26.8%, respectively, and
relative frequent causative diseases were listed in Table 1.
Peripheral vertigo was frequently induced by benign
paroxysmal positional vertigo (BPPV), vestibular neuronitis, Meniere’s disease. In addition, it also attributes to
impairment of inner ear (three cases, the same in below),
31
Table 1
The main causative diseases of vertigo
n
%
Peripheral
Benign paroxysmal positional vertigo
Vestibular neuronitis
Meniere’s disease
Sudden hearing loss
Vestibular dysfunction
Delayed endolymphatic hydrops
Hearing loss
Labyrinth concussion
Hunt’s syndrome
Superior canal dehiscence syndrome
Others
734
149
108
96
31
20
19
7
5
5
3
291
33.8
6.9
5.0
4.4
1.4
0.9
0.9
0.3
0.2
0.2
0.1
13.4
Central
Vertebro-basilar insufficiency
Spinocerebellar degeneration
Wallenberg’s syndrome
Tumor of cerebella and brain stem
AICA syndrome
Arnold–Chiari syndrome
Others
373
231
36
4
8
3
2
89
17.2
10.7
1.7
0.2
0.4
0.1
0.1
4.1
Unclassified
Acoustic tumor
Positional vertigo
Orthostatic hypotension
Depression state
High blood pressure
Cervical vertigo
Congenital nystagmus
Others
581
137
109
81
26
20
16
11
181
26.8
6.3
5.0
3.7
1.2
0.9
0.7
0.5
8.3
481
22.2
Unknown
Total
2169
100
complication of cochlear implant (3), otitis media (3),
perilymph fistula (2), malformation of inner ear (2),
labyrinth syphilis (1), Bell’s palsy (1), and so on.
Vertebro-basilar insufficiency (VBI), and spinocerebellar degeneration (SCD) were recognized as the
main causative diseases in central vertigo. Besides,
impairment of cerebellum (3), brain stem (5), mitochondrial myopathy (2), olivopontocerebellar atrophy (2), one
and half syndrome (2), Fisher syndrome (1), Cogan
syndrome (1), cervico-vestibular syndrome (1), Freidleich
ataxia (1), neurocascular compression syndrome (1),
post traumatic syndrome (2), basilar impression (1),
Wernicke–Korsakoff syndrome (1), and so on were also
recognized.
Acoustic tumor, positional vertigo, and orthostatic
hypotension (OD) were considered as the main causes in
the unclassified vertigo. Vogt–Koyanagi–Harada syndrome
(4), drug (phenytoin, 3), low blood pressure (3), sleep
disorder (3), heart disease (2), virus (1), measles (1),
polyarteritis nodosa (1), and so on, were also defined.
Besides, VBI and OD were concurrent in 37.2% of VBI and
51.5% of OD patients.
32
M. Yin et al. / Auris Nasus Larynx 36 (2009) 30–35
Fig. 1. The age distribution of vertigo patients and the estimated yearly
incidence rate. The yearly incidence rate was estimated based on the results
of population survey of Akita city.
3.2. The incidence characteristics of vertigo
The patients with vertigo generally increased with age
and reached its peak in the 60s, for both male and female
(Fig. 1). The peak age of peripheral vertigo was 50–60 years,
which was 10 years earlier than central vertigo (60–70 years)
and unclassified vertigo (60 years) (Fig. 2A). This trend was
also observable in most causative diseases (Fig. 2B), but not
in delayed endolymphatic hydrops, depressive state, and
hypertension, and cervical vertigo. Vestibular dysfunction
and SCD seemed to attack mainly in adult patients of more
than middle age, but not in the younger generation.
Although female patients were obviously more than males,
there was no significant difference in the incidence rate
between them (Fig. 1). Generally, the gender difference was
significant in peripheral and unclassified vertigo ( p < 0.001),
but not in central vertigo ( p > 0.05, Table 2). The gender
difference for individual causative disease was shown in
Table 3 and Fig. 3.
Fig. 2. The increasing tendency with age for each category (A), and typical
causative disease (B). BPPV = benign paroxysmal positional vertigo;
VBI = vertebro-basilar insufficiency; SCD = spinocerebellar degeneration;
OD = orthostatic hypotension.
In juveniles, central vertigo is quite limited (only 4 cases).
Although OD (6 cases), AT (5 cases), BPPV (3 cases) and
Meniere’s disease (2 cases) seemed to be relatively more, the
causative diseases were various and no predominate disease
was defined.
Within the continuous 20 years, the elderly patients with
vertigo showed an increasing tendency ( p < 0.01, Fig. 4).
Central vertigo presented itself much more in elderly
patients than in the younger. The elderly patients’ ratio in the
causative disease and the distribution of causative disease
for elderly patients were shown in Fig. 5. Nearly half of
patients were elderly in VBI and OD, which were also
contributed to one third of the cause for the elders.
3.3. The characteristics of vertigo in juveniles and
elders
Juvenile group (<18 years) occupied 2.2% (48 cases) of
the total vertigo patients, while elders occupied 30.0% (650
cases). They presented different constituent of vertigo
categories in comparison with adults (18–65 years, Table 2).
Table 2
Distribution of juveniles, adults and elders for each vertigo category
Total (%), n = 2169
Total
Peripheral
Central
Unclassified
Others
Total
Juveniles (%), n = 48
Total
Elders (%), n = 650
M
F
M
F
M
F
M
F
33.8
17.2
26.8
22.2
13.3
8.2
10.6
8.7
20.6
9.0
16.2
13.5
29.2
8.3
41.7
20.8
14.6
6.3
25.0
8.3
14.6
2.1
16.7
12.5
36.2
12.5
28.3
23.0
14.2
6.0
11.3
9.4
22.0
6.5
17.0
13.6
28.8
28.5
22.3
20.5
11.1
13.2
8.0
7.1
17.7
15.2
14.3
13.4
100.0
40.7
59.3
100.0
54.2
45.8
100.0
40.9
59.1
100.0
39.4
60.6
M = male; F = female.
Total
Adults (%), n = 1471
Total
M. Yin et al. / Auris Nasus Larynx 36 (2009) 30–35
33
Table 3
Character of typical causative disease
Benign paroxysmal positional vertigo
Vestibular neuronitis
Meniere’s disease
Sudden deafness
Vertebro-basilar insufficiency
Spinocerebellar degeneration
Acoustic tumor
Positional vertigo
Orthostatic hypotension
n
%
Sex ratio (F:M)
Age range
Peak age
149
108
96
31
231
36
137
109
81
6.9
5.0
4.4
1.4
10.7
1.7
6.3
5.0
3.7
1.44
1.04
2.31
1.21
1.18
0.64
1.28
1.95
1.61
7–86
24–85
12–75
24–77
19–87
10–79
13–82
21–84
11–90
50s
60s
40–60s
40–60s
60–70s
50–60s
60s
60s
60s
4. Discussion
Previous studies presented different data on the causative
diseases and their distributions for each category of vertigo
[4–6,10]. However, the subjects in these studies were too
limited (no more than 200 patients) to illustrate the various
causative diseases. More over, different settings were also
found in previous studies, such as in clinic [4], in primary
care [5], or in ambulatory care [6], which considerably
attributed to different results. Due to the variety of causative
diseases, a certain number of patients should be necessary to
describe its character. In order to solve the problem, our
study was specially designed in Akita University hospital
that is core hospital in this district. Akita city lies in the
northern of Japan, with a population of around 310,000
according to the last national population census by the
government in 2005. As the life span of residents is one of
the longest in the world, the patients’ age in our study ranged
from seven to nineties, which could reflect all year grades.
All data were based on the same diagnostic criteria, and the
results could be considered representative. On another hand,
Fig. 3. Gender difference for each causative disease. NS: no significance;
*p < 0.05; #p < 0.01; Dp < 0.005. SCD = spinocerebellar degeneration;
VN = vestibular neuronitis; SHL = sudden hearing loss; VBI = vertebrobasilar insufficiency; AT = acoustic tumor; BPPV = benign paroxysmal
positional vertigo; OD = orthostatic hypotension.
Fig. 4. Increasing of elderly patients.
Fig. 5. The causative diseases for elderly patients. (A) The elderly patients’
ratio in the causative disease and (B) the distribution of causative disease for
elderly patients. VBI = vertebro-basilar insufficiency; OD = orthostatic
hypotension; BPPV = benign paroxysmal positional vertigo; VN = vestibular neuronitis; AT = acoustic tumor; SCD = spinocerebellar degeneration.
34
M. Yin et al. / Auris Nasus Larynx 36 (2009) 30–35
as the study was carried out in the department of otolaryngology, some professional features could be recognized.
More than 50 kinds of causative diseases were experienced
that consisted of nearly one third of peripheral vertigo, 17.2%
of central and 26.8% of unclassified vertigo. There was still
22.2% of vertigo with unclear etiological cause. This result
was similar with the previous review that summarized the
individual results [11]. VBI and AT seemed to be impressive
in our data. VBI patients took up of 10.7% (231 cases). Higher
prevalence of VBI in aged population was known. According
to our data, in comparison with other causative diseases, both
the high ratio of the elders in VBI patients (57.8 and
73.6% > 60 years), and the high proportion of VBI in elderly
patients (20.8%), were outstanding. These results had never
been pointed out before [8,12]. Akita city is a super-aging
society and its elder population accounted more than 25.5%.
This may mostly contribute to a higher proportion of VBI
patients in our study. Nowadays, early diagnosis of small AT is
accessible by the help of Gd-enhanced MRI scan. Our
department is specific in AT and many AT patients referred to
our department. Thus, AT patients (6.3%, 137 cases) with
vertigo were much more than usual. Meanwhile, migraine
related vertigo was very rare, because these patients would
usually visit other departments firstly. These regional and
professional features suggest some limitations of our data on
another hand.
Gender difference was pointed out previously in some
studies with a sex ratio (female:male) of 1.7–2:1 [13]. From
our data, females were also more than males (1.5:1), in both
central and peripheral vertigo. However, no significant
difference was confirmed in the estimated yearly incidence
rate if controlled by population. Preponderant attack in
female patients could be observed among most causative
diseases but with a notable exception. In SCD, males were
obviously more than females (1.57:1). This was very close to
the result of national epidemiological and clinical study in
Japan from 1988 to 1989, in which a sex ratio (male:female)
of 1.5:1 was recognized [14]. Vestibular neuronitis and
sudden hearing loss also showed no sexual difference, which
also matched previous results in Japan [15,16].
An increasing tendency with age was also reported in
other study [13]. Our data furthermore confirmed the
tendency in most causative diseases, both peripheral and
central patients, such as BPPV, vestibular neuronitis,
Meniere’s disease, sudden deafness, VBI, SCD, AT,
positional vertigo and OD (Fig. 2). No increasing tendency
was confirmed for delayed endolymphatic hydrops, depressive state, hypertension and cervical vertigo. It might be
because the cases were still too scant (<20 cases).
Vertigo of elderly patients occupied 38.5% of total and
central vertigo turned more (28.5%), nearly the same as the
peripheral vertigo. Morphological findings and vestibular
function testing revealed the age-related degenerative
processes [17]. The degeneration of the central and the
vascular system may suggest that elderly population may be
susceptible to vertigo [18], especially to the central vertigo.
In addition, this clinical tendency might also be attributed to
the increasing of aged population in the district.
Through our observation, children’s vertigo only takes
2.2% of the total. As the data of vertigo in children were rare,
the results differed to some extend in our data from other
studies [8,19]. Combined with these data, we can find that
peripheral vertigo dominates in children, while central
vertigo is much rare. In our data, no predominant causative
disease was pointed out. However, benign paroxysmal
vertigo of childhood, migraine associated vertigo, vestibular
neuronitis and otitis media related dizziness seemed to be
the main reasons. Sexual difference was not confirmed
according to previous data [7,20] and ours.
In summary, we reported more 50 kinds of causative
diseases for vertigo and described their epidemiological
characteristics. Generally vertigo it is important to make a
certain etiological diagnosis for a patient with vertigo.
References
[1] Neuhauser HK, von Brevern M, Radtke A, Lezius F, Feldmann M,
Ziese T, et al. Epidemiology of vestibular vertigo: a neurotologic
survey of the general population. Neurology 2005;65:898–904.
[2] Aggarwal NT, Bennett DA, Bienias JL, Mendes de Leon CF, Morris
MC, Evans DA. The prevalence of dizziness and its association with
functional disability in a biracial community population. J Gerontol A:
Biol Sci Med Sci 2000;55:M288–92.
[3] Yardley L, Owen N, Nazareth I, Luxon L. Prevalence and presentation
of dizziness in a general practice community sample of working age
people. Br J Gen Prac 1998;48:1131–5.
[4] Guilemany JM, Martinez P, Prades E, Sanudo I, Espana DE, Cuchi A.
Clinical and epidemiological study of vertigo at an outpatient clinic.
Acta Otolaryngol 2004;124:49–52.
[5] Sloane P, Dallara J, Roach C, Bailey KE, Mitchell M, McNutt R.
Management of dizziness in primary care. J Am Board Fam Prac
1994;7:1–8.
[6] Kroenke K, Lucas CA, Rosenberg ML, Scherokman B, Herbers Jr JE,
Wehrle PA, et al. Causes of persistent dizziness. A prospective study of
100 patients in ambulatory care. Ann Intern Med 1992;117:898–904.
[7] Riina N, Ilmari P, Kentala E. Vertigo and imbalance in Children. Arch
Otolaryngol Head Neck Surg 2005;131:996–1000.
[8] Katsarkas A. Dizziness in aging: a retrospective study of 1194 cases.
Otolaryngol Head Neck Surg 1994;110:296–301.
[9] The Standardization Committee of the Japan Society of Equilibrium
Research. The standard diagnostic criteria for vertigo. Equilibrium
Res 1988; 47:245–273.
[10] Lawson J, Fitzgerald J, Birchall J, Aldren CP, Kenny RA. Diagnosis of
geriatric patients with severe dizziness. J Am Geriatr Soc 1999;47:
12–7.
[11] Kroenke K, Hoffman RM, Einstadter D. How common are various
causes of dizziness? A critical review. South Med J 2000;93:160–7.
[12] Davis LE. Dizziness in elderly men. Geriatr Soc 1994;42:1184–8.
[13] Sekine K, Sato G, Takeda N. Incidence of vertigo and dizziness
disorders at a university hospital. Nippon Jibiinkoka Gakkai Kaiho
2005;108:842–9.
[14] Hirayama K, Takayanagi T, Nakamura R, Yanagisawa N, Hattori T,
Kita K, et al. Spinocerebellar degenerations in Japan: a nationwide
epidemiological and clinical study. Acta Neurol Scand Suppl
1994;153:1–22.
[15] Sekitani T, Imate Y, Noguchi T, Inokuma T. Vestibular neuronitis:
epidemiological survey by questionnaire in Japan. Acta Otolaryngol
Suppl 1993;503:9–12.
M. Yin et al. / Auris Nasus Larynx 36 (2009) 30–35
[16] Nakashima T, Itoh A, Misawa H, Ohno Y. Clinicoepidemiologic
features of sudden deafness diagnosed and treated at university
hospitals in Japan. Otolaryngol Head Neck Surg 2000;123:593–7.
[17] Furman JM, Redfern MS. Effect of aging on the otolith-ocular reflex. J
Vestib Res 2001;11:91–103.
[18] Jonsson R, Sixt E, Landahl S, Rosenhall U. Prevalence of dizziness and
vertigo in an urban elderly population. J Vestib Res 2004;14:47–52.
35
[19] Choung YH, Park K, Moon SK, Kim CH, Ryu S. Various cases and
clinical characteristics in vertigo in children with normal eardrums.
Int J Pediatr Otolaryngol 2003;67:889–94.
[20] Niemensivu R, Pyykko I, Wiener-Vacher SR, Kentala E. Vertigo and
balance problems in children—an epidemiologic study in Finland. Int
J Pediatr Otorhinolaryngol 2006;70:259–65.