Special Article
Peripheral Vertigo Classification of the Otoneurology Committee of the Spanish Otorhinolaryngology Society: Diagnostic Agreement and Update (Version 2-2011)
Clasificación de los vértigos periféricos de la Comisión de Otoneurología de la Sociedad Española de Otorrinolaringología: concordancia diagnóstica y actualización (versión 2, año 2011)
Andrés Soto-Varelaa,
, Ismael Arán-Gonzálezb,1, José Antonio López-Escámezc, Constantino Morera-Pérezd, Manuel Oliva-Domíngueze, Nicolás Pérez-Fernándezf,1, Herminio Pérez-Garriguesd,1, Paz Pérez-Vázquezg,1, Marcos Rossi-Izquierdoh, Sofía Santos-Péreza
Corresponding author
a Servicio de Otorrinolaringología, Complexo Hospitalario Universitario de Santiago, Santiago de Compostela, A Coruña, Spain
b Servicio de Otorrinolaringología, Complexo Hospitalario de Pontevedra, Pontevedra, Spain
c Servicio de Otorrinolaringología, Grupo Otología & Otoneurología CTS495, Hospital del Poniente, El Ejido, Almería, Spain
d Servicio de Otorrinolaringología, Hospital Universitario La Fe, Valencia, Spain
e Servicio de Otorrinolaringología, Hospital Costa del Sol, Marbella, Málaga, Spain
f Departamento de Otorrinolaringología, Clínica Universidad de Navarra, Pamplona, Navarra, Spain
g Servicio de Otorrinolaringología, Hospital de Cabueñes, Gijón, Asturias, Spain
h Servicio de Otorrinolaringología, Hospital Lucus Augusti, Lugo, Spain
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Ejido, Almería, Spain" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital Universitario La Fe, Valencia, Spain" "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital Costa del Sol, Marbella, Málaga, Spain" "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Departamento de Otorrinolaringología, Clínica Universidad de Navarra, Pamplona, Navarra, Spain" "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital de Cabueñes, Gijón, Asturias, Spain" "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Otorrinolaringología, Hospital Lucus Augusti, Lugo, Spain" "etiqueta" => "<span class="elsevierStyleSup">h</span>" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Clasificación de los vértigos periféricos de la Comisión de Otoneurología de la Sociedad Española de Otorrinolaringología: concordancia diagnóstica y actualización (versión 2, año 2011)" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1313 "Ancho" => 1991 "Tamanyo" => 77904 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diagnostic agreement (agreement between at least 4 reviewers).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with vertigo are often particularly a diagnostic chanllenge for otolaryngologists. Vagueness in the explanation of their symptoms and difficulty to interpret them are often worsened by variability in the naming of clinical symptoms. Despite various attempts to classify vertigo (or the entities which cause it),<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> reality has shown that, even among otolaryngologists with specific experience in Otoneurology, there is no common language enabling simple communication when establishing diagnoses and treatment protocols. This fact has also been noted internationally by the Bárány Society.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">With this reality in mind, and as an attempt to establish a simple nomenclature accepted by all, the Otoneurology Commission of SEORL-PCF developed a proposal for the classification of peripheral vertigo between 2003 and 2006. After being reviewed and evaluated by various Spanish otoneurologists, it was published as a consensus document in Acta Otorrinolaringológica Española in the year 2008,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and later quoted in a publication by the Bárány Society in 2009.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In the same year 2009, the Otoneurology Commission of SEORL-PCF proposed a validation of this classification, in order to test its usefulness in clinical practice. The aim was threefold:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">–</span><p id="par0020" class="elsevierStylePara elsevierViewall">To determine the percentage of patients attending consultation due to vertigo and balance disorders who could be included within each section of the classification.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">–</span><p id="par0025" class="elsevierStylePara elsevierViewall">To establish the level of agreement between different clinical evaluators in the diagnoses of these same patients, using the criteria described in this classification.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">–</span><p id="par0030" class="elsevierStylePara elsevierViewall">To conduct, if appropriate, a modification in the classification whenever limitations were detected and there was a consensus on how to address them.</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Material and Methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">A multicentre study was designed, involving 1 coordinator and 6 different evaluators, all of them otolaryngologists specifically involved with Otoneurology and from 6 different centres.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The coordinator selected the clinical records of 50 consecutive patients who attended the otoneurology clinic at Hospital Universitario de Santiago due to vertigo and balance disorders and for whom, in his judgement, it was possible to obtain a diagnosis. The patients were 24 males and 26 females, with a mean age of 53.5 years (with a minimum of 8 and a maximum of 89 years). The following information was excluded from these histories:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">–</span><p id="par0045" class="elsevierStylePara elsevierViewall">Name and identification details of the patients, in order to preserve their privacy.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">–</span><p id="par0050" class="elsevierStylePara elsevierViewall">Diagnosis proposed by the study coordinator.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">–</span><p id="par0055" class="elsevierStylePara elsevierViewall">Treatment indicated (since it could be indicative of the diagnosis).</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">Consequently, the medical records included:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">–</span><p id="par0065" class="elsevierStylePara elsevierViewall">Demographic data of patients: age, gender, marital status, occupation and toxic habits (alcohol, tobacco and/or caffeine consumption and exposure to noise).</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">–</span><p id="par0070" class="elsevierStylePara elsevierViewall">Clinical data: personal and family medical history, current use of medication, reason for consultation and detailed otoneurological history.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">–</span><p id="par0075" class="elsevierStylePara elsevierViewall">Exploration data:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0080" class="elsevierStylePara elsevierViewall">General otolaryngology clinical examination.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">•</span><p id="par0085" class="elsevierStylePara elsevierViewall">Neurological examination (cranial nerves, strength, sensitivity and coordination tests).</p></li></ul></p></li></ul><ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">–</span><p id="par0090" class="elsevierStylePara elsevierViewall">Clinical, otoneurological and balance examination:</p></li></ul><ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">•</span><p id="par0095" class="elsevierStylePara elsevierViewall">Exploration of spontaneous nystagmus (with naked eye and with Frenzel goggles).</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">•</span><p id="par0100" class="elsevierStylePara elsevierViewall">Halmagyi and head shaking tests.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">•</span><p id="par0105" class="elsevierStylePara elsevierViewall">Unteberger and Romberg tests.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">•</span><p id="par0110" class="elsevierStylePara elsevierViewall">Positional tests (whenever listed): Dix and Hallpike, McClure and/or cephalic hyperextension tests.</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">•</span><p id="par0115" class="elsevierStylePara elsevierViewall">Tone threshold audiometry.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">•</span><p id="par0120" class="elsevierStylePara elsevierViewall">Instrumental balance tests (as indicated for each patient): videonystagmography (caloric and/or rotating tests), dynamic posturography, craniocorpography and/or vestibular evoked myogenic potentials.</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">•</span><p id="par0125" class="elsevierStylePara elsevierViewall">Other tests, including analytical, audiological (otoacoustic emissions and/or auditory evoked potentials) and/or imaging tests (brain MRI scan and/or petrosal CT scan).</p></li></ul></p><p id="par0130" class="elsevierStylePara elsevierViewall">These 50 clinical histories were simultaneously referred to the 6 reviewers. All were asked for:<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">–</span><p id="par0135" class="elsevierStylePara elsevierViewall">A diagnosis of each patient, attempting to follow the sections in the consensus classification.</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">–</span><p id="par0140" class="elsevierStylePara elsevierViewall">A personal diagnosis for each patient.</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">–</span><p id="par0145" class="elsevierStylePara elsevierViewall">Comments on the difficulties encountered to match each patient to a section in the classification.</p></li></ul></p><p id="par0150" class="elsevierStylePara elsevierViewall">The diagnoses and comments from each of the evaluators were collected in an Excel spreadsheet. Statistical analysis of the results was performed using SPSS 15.0 for Windows. The kappa index was used to analyse diagnostic agreement.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><p id="par0155" class="elsevierStylePara elsevierViewall">First, we analysed the percentage of patients whom the assessors found it possible to define a diagnostic category included in the consensus classification. We considered 3 possibilities:<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">–</span><p id="par0160" class="elsevierStylePara elsevierViewall">A diagnosis was established and it formed part of the classification.</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">–</span><p id="par0165" class="elsevierStylePara elsevierViewall">A diagnosis was established, but it was not contemplated by the classification.</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">–</span><p id="par0170" class="elsevierStylePara elsevierViewall">It was not possible to establish a diagnosis with the information available.</p></li></ul></p><p id="par0175" class="elsevierStylePara elsevierViewall">The percentage of patients included by each of the evaluators is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. According to reviewers, the percentage of patients for whom it was not possible to establish a diagnosis described in the consensus classification ranged between 24% and 48% of the total.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0180" class="elsevierStylePara elsevierViewall">Next, we proceeded to analyse the level of diagnostic agreement between the evaluators. We considered 2 options:<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">–</span><p id="par0185" class="elsevierStylePara elsevierViewall">Patients in whom there was unanimity in diagnosis among the 6 evaluators: 7 patients (14% of total). These were 4 patients with benign paroxysmal positional vertigo, 2 with Meniere's disease and 1 with migraine-associated vertigo.</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">–</span><p id="par0190" class="elsevierStylePara elsevierViewall">Patients with majority agreement (at least 4 of the evaluators agreed on the diagnosis based on the classification): 31 patients (62%). Of these, the agreement was positive (there was agreement that it was possible to establish a diagnosis included in the classification) in 26 patients (52% of total) and negative (it was agreed that it was not possible to include the patient in any of the sections of the classification) in 5 cases (10% of total). This agreement is shown as a graph in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li></ul></p><p id="par0195" class="elsevierStylePara elsevierViewall">We used the kappa index for the statistical analysis of agreement between evaluators, measuring the agreement between 3 or more observers with 2 categories. In this case the 2 categories were the following:<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">–</span><p id="par0200" class="elsevierStylePara elsevierViewall">A diagnosis was established.</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">–</span><p id="par0205" class="elsevierStylePara elsevierViewall">A diagnosis was not established (“vertigo of unknown origin” or “cannot be included in the classification”).</p></li></ul></p><p id="par0210" class="elsevierStylePara elsevierViewall">The level of agreement indicated by the result of the kappa index is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>. Under the above conditions, in our series of patients the kappa index value was 0.4198, with a 95% confidence interval and a value of <span class="elsevierStyleItalic">P</span><.00001. This indicates a moderate level of agreement.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">Finally, we collected the comments of various evaluators on the difficulties encountered to include patients in each section of the classification. These comments were summarised as follows:<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">–</span><p id="par0220" class="elsevierStylePara elsevierViewall">Some patients did not report vertigo crises, but rather instability or imbalance, so they could not be included in any of the sections of the classification.</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">–</span><p id="par0225" class="elsevierStylePara elsevierViewall">The diagnosis of benign paroxysmal positional vertigo requires positive evidence at the time of diagnosis. Thus, it was not possible to include those patients who reported compatible clinical symptoms which had been resolved at the time of consultation.</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">–</span><p id="par0230" class="elsevierStylePara elsevierViewall">Some evaluators reported that there were some diagnostic possibilities missing:<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">•</span><p id="par0235" class="elsevierStylePara elsevierViewall">Vestibulotoxicity.</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">•</span><p id="par0240" class="elsevierStylePara elsevierViewall">Presbyvertigo/presbyastasia.</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">•</span><p id="par0245" class="elsevierStylePara elsevierViewall">Intoxication/drug side effects.</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">•</span><p id="par0250" class="elsevierStylePara elsevierViewall">Acute vestibular episode lasting hours (duration not specified in neuritis).</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">•</span><p id="par0255" class="elsevierStylePara elsevierViewall">Recurrent peripheral vertigo.</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">•</span><p id="par0260" class="elsevierStylePara elsevierViewall">Phobic postural vertigo and anxiety.</p></li></ul></p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0265" class="elsevierStylePara elsevierViewall">The existence of a consensus nomenclature which enabled the categorisation of patients with vertigo based on clinical data and ease of use was a common demand of otolaryngologists involved in Otoneurology. The consensus classification proposed by the Otoneurology Commission of SEORL-PCF was developed in an attempt to respond to this demand.</p><p id="par0270" class="elsevierStylePara elsevierViewall">The current validation was conducted in an attempt to adapt to the clinical reality of patients with vertigo and balance disorders. To this end, a group of patients who consulted consecutively due to vertigo or balance disorders at a specialised Otoneurology unit were collected without applying selection or exclusion criteria. This was simultaneously an advantage (it adjusted to the reality of consultation) and a limitation (not all patients referred to Otoneurology units were adequately pre-screened, so there could be many patients who did not really suffer vertigo or instability).</p><p id="par0275" class="elsevierStylePara elsevierViewall">A second limitation was due to the methodological design of the study. The evaluators only had access to the information which the study coordinator sent them and which he considered sufficient to establish a diagnosis. However, this may not have been the same for the evaluators. Moreover, a diagnosis established from a clinical history written by a third person has limitations with respect to a diagnosis “in person”, due to the additional information that can be obtained in the latter case (possibility of delving deeper during questioning, information provided by body language, etc.).</p><p id="par0280" class="elsevierStylePara elsevierViewall">Once these considerations were taken into account, the level of agreement achieved (measured as the kappa index value) showed the need for improvements in the classification in order to obtain a substantially higher level of agreement. The results of this assessment were discussed, not only between the coordinator and evaluators, but also among a larger group of otoneurologists in September 2010 in Madrid and subsequently via email, so that the classification modification was obtained by consensus. Two modifications were proposed. The first was the inclusion of a new section under the heading “recurrent vertigo crises without hypoacusis, caused by posture”, dividing it into 2 sections:<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">–</span><p id="par0285" class="elsevierStylePara elsevierViewall">Definitive BPPV: according to the prior definition of the classification: “brief vertigo (usually lasting seconds), caused by positional triggering tests (Dix and Hallpike test, lateral position test, rotation test or cephalic hyperextension test) which is finite and reproducible”.</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">–</span><p id="par0290" class="elsevierStylePara elsevierViewall">Probable BPPV: clinical manifestations suggestive of BPPV, but with negative positional tests at the time of consultation (due to spontaneous resolution of symptoms).</p></li></ul></p><p id="par0295" class="elsevierStylePara elsevierViewall">The second change was the review and update of the diagnoses of “vertigo-migraine” and “migraine-associated vertigo”, which were replaced by “basilar-type migraine” and “vestibular migraine”, respectively, based on bibliographic information subsequent to the publication of the first classification. With these modifications, the consensus classification of vertigo by the Otoneurology Commission of SEORL-PCF would be as reflected in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>. The definition of each section, including the modifications already described for BPPV, vertigo-migraine and migraine-associated vertigo, are transcribed as an annex from the initial publication.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0300" class="elsevierStylePara elsevierViewall">Another result of the reflections and consultations conducted for this assessment was a commitment by the Otoneurology Commission of SEORL-PCF to reassess the classification in a dynamic manner. This will enable its effectiveness to be determined and aid in reaching new agreements over entities for which a definitive consensus could not be reached at the time (presbyvertigo, ototoxicity, etc.).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of Interest</span><p id="par0305" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres94973" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec82124" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres94972" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec82125" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflicts of Interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-10-07" "fechaAceptado" => "2011-10-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec82124" "palabras" => array:3 [ 0 => "Vertigo" 1 => "Classification" 2 => "Otoneurology" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec82125" "palabras" => array:3 [ 0 => "Vértigo" 1 => "Clasificación" 2 => "Otoneurología" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In 2008, the Otoneurology committee of the SEORL-PCF published a classification of peripheral vertigo, based on clinical criteria. The objective of this study was to validate this classification through analysing the diagnostic agreement among several medical assessors.</p> <span class="elsevierStyleSectionTitle">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Seven medical assessors, all with clinical experience, from 6 different hospitals, participated in the study. One of them selected the clinical histories of 50 consecutive patients who had consulted as a result of balance disorders (24 men and 26 women) with an average age of 53.5 years. These clinical histories – without any information that would identify the patient, the diagnosis established and the treatment – were sent to another 6 assessors. Each of these investigators established their own diagnosis, trying to adjust it to the epigraphs of the classification.</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Of the 50 patients, there was substantial agreement in the diagnosis (4 or more evaluators indicated the same one) in 31 cases (26 with a positive diagnosis and 5 with a negative one, which could not be included in any epigraph). The kappa index, which measures the level of accordance between 2 or more assessors, was 0.4198 (moderate level of agreement). Unanimity was achieved in only 7 cases (4 BPPV, 2 Ménière's disease and 1 vertigo associated with migraine).</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The current classification, with the included criteria it includes, allows labelling with an acceptable consensus to only 62% of the patients. Therefore, a modification in the classification is proposed in relation with the probable BPPV epigraph, as well as a revision of the entries for vertigo-migraine and vertigo associated with migraine.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle">Introducción</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La Comisión de Otoneurología de la SEORL-PCF publicó en 2008 una clasificación de los vértigos periféricos, basada en criterios clínicos. El objetivo de este estudio es validar esta clasificación mediante el análisis de la concordancia diagnóstica entre múltiples evaluadores.</p> <span class="elsevierStyleSectionTitle">Métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Participaron 7 evaluadores con experiencia clínica en el diagnóstico de afección vestibular, pertenecientes a 6 centros diferentes. Uno de ellos seleccionó las historias clínicas de 50 pacientes consecutivos que consultaron por alteraciones del equilibrio (24 varones y 26 mujeres; edad media: 53,5 años). Estas historias, suprimidos los datos que permitiesen identificar a los pacientes, el diagnóstico establecido y el tratamiento pautado, fueron remitidas a los otros 6 investigadores. Cada uno de ellos estableció un diagnóstico, intentando ajustarlo a los epígrafes de la clasificación.</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">De los 50 pacientes, existió una coincidencia sustancial en el diagnóstico (4 o más evaluadores alcanzaron el mismo) en 31 (26 con diagnóstico positivo y 5 negativo: no podía ser incluido en ningún epígrafe). El índice kappa, que mide el nivel de concordancia entre tres o más observadores, fue de 0,4198 (lo que indica un grado de acuerdo moderado). La unanimidad solo se alcanzó en 7 pacientes (4 VPPB, dos enfermedades de Ménière y un vértigo asociado a migraña).</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La actual clasificación, con los criterios que incluye, solo permite etiquetar con un consenso aceptable al 62% de los pacientes. Se propone una modificación de la clasificación, incluyendo el epígrafe de VPPB probable, y revisando los de vértigo-migraña y vértigo asociado a migraña.</p>" ] ] "NotaPie" => array:2 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "<p class="elsevierStyleNotepara">Member of the Otoneurology Commission of SEORL-PCF.</p>" "identificador" => "fn0005" ] 1 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Soto-Varela A, et al. Clasificación de los vértigos periféricos de la Comisión de Otoneurología de la Sociedad Española de Otorrinolaringología: concordancia diagnóstica y actualización (versión 2, año 2011). Acta Otorrinolaringol Esp. 2012;63:125–31.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "etiqueta" => "Appendix 1" "titulo" => "Definitions of the Sections of the Classification" "identificador" => "sec0030" "apendiceSeccion" => array:2 [ 0 => array:4 [ "apendice" => "<p id="par0310" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Acute vertigo with hearing loss</span></span>. Clinical syndrome characterised by hearing loss with a sudden vertigo crisis, diaphoresis, spontaneous nystagmus and postural imbalance. It may also appear with: (a) cochlear involvement (labyrinthitis) with an otogenous, vascular, tumoural or degenerative cause, and (b) cochleovestibular neuritis: otic herpes zoster (Ramsay–Hunt syndrome).</p> <p id="par0315" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Acute vertigo without hearing loss: vestibular neuritis.</span></span> Clinical syndrome characterised by the sudden onset of a prolonged vertigo crisis, with nausea and vomiting, spontaneous nystagmus and postural imbalance, without neurological or hearing symptoms.</p>" "etiqueta" => "A.1" "titulo" => "Single Vertigo Crises" "identificador" => "sec0035" ] 1 => array:4 [ "etiqueta" => "A.2" "titulo" => "Recurrent Vertigo Crises" "identificador" => "sec0040" "apendiceSeccion" => array:2 [ 0 => array:4 [ "apendice" => "<p id="par0320" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Ménière's disease</span>. In order to be included in this group, the patient must have suffered at least 2 episodes typical of vertigo (of at least 20<span class="elsevierStyleHsp" style=""></span>min duration, accompanied by imbalance and often nausea and sweating, requiring rest, and always presenting horizontal or horizontal-rotary nystagmus). Hearing loss must be of perceptive type, verified at least once through audiometric tests (it is common for hearing to fluctuate, but it is not essential for diagnosis). The affected ear must present tinnitus, aural fullness or both. This would correspond to what the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) defined as “definite MD”.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It would also include other clinical forms such as familial Meniere's vertigo (MV), due to a likely genetic alteration, and bilateral MV (synchronous and asynchronous).</p> <p id="par0325" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Basilar-type migraine</span> (code 1.2.6. of the ICHD-II).<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Vertigo is present in 60% of patients with basilar-type migraine.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> It is defined as a migraine headache with aura which presents at least 2 of the following, fully reversible, neurological symptoms:<ul class="elsevierStyleList" id="lis0070"><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">–</span><p id="par0330" class="elsevierStylePara elsevierViewall">Dysarthria.</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">–</span><p id="par0335" class="elsevierStylePara elsevierViewall">Vertigo.</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">–</span><p id="par0340" class="elsevierStylePara elsevierViewall">Tinnitus.</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">–</span><p id="par0345" class="elsevierStylePara elsevierViewall">Hearing loss.</p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">–</span><p id="par0350" class="elsevierStylePara elsevierViewall">Diplopia.</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">–</span><p id="par0355" class="elsevierStylePara elsevierViewall">Simultaneous visual symptoms in both eyes and both nasal and temporal visual fields.</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">–</span><p id="par0360" class="elsevierStylePara elsevierViewall">Ataxia.</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">–</span><p id="par0365" class="elsevierStylePara elsevierViewall">Decreased level of consciousness.</p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">–</span><p id="par0370" class="elsevierStylePara elsevierViewall">Simultaneous bilateral paresthesias.</p></li></ul></p> <p id="par0375" class="elsevierStylePara elsevierViewall">The presence of motor impairment excludes this diagnosis. The symptoms associated by basilar-type migraine are typically associated with those of the posterior fossa and are usually bilateral. It is necessary for one of the aura symptoms to develop gradually over 5<span class="elsevierStyleHsp" style=""></span>min or for various aura symptoms to occur in succession for over 5<span class="elsevierStyleHsp" style=""></span>min. In addition, each aura symptom must last for at least 5<span class="elsevierStyleHsp" style=""></span>min and up to a maximum 60<span class="elsevierStyleHsp" style=""></span>min.</p> <p id="par0380" class="elsevierStylePara elsevierViewall">It was previously classified as basilar migraine. The terminology has been modified because there is little evidence that the basilar artery or its territory are involved. ICHD-II recognises vertigo as an aura of basilar-type migraine.</p> <p id="par0385" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Autoimmune inner ear disease</span>. Clinical symptoms characterised by vertigo and sudden sensorineural hearing loss, rapidly progressive and/or episodic, with good response to treatment with corticosteroids and immunosuppressors, in the context of a systemic autoimmune disease and/or alterations in any of the following laboratory tests: elevated sedimentation rate, positive rheumatoid factor, positive antinuclear antibodies, positive antineutrophil cytoplasmic antibodies, elevated circulating immune complexes, positive Western blot and T16 cell immunophenotype.</p> <p id="par0390" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Neurosyphilis-otosyphilis</span>. Includes patients with episodic vertigo with unilateral or bilateral, progressive, perceptive hearing loss. Patients present unilateral or bilateral vestibular hypofunction and analytical studies are positive for syphilis.</p> <p id="par0395" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Perilymphatic fistula</span>. Characterised by vertigo with progressive sensorineural hearing loss, with stepwise evolution and history of middle-internal ear malformations, (observed by CT and MRI scan), head injury or surgery with manipulation of oval or round window and/or visualisation of the fistula during surgery. Fistula test should be positive (although not in all cases). Most cases present labyrinth hypoexcitability in the thermal test.</p>" "etiqueta" => "A.2.1" "titulo" => "Recurrent Vertigo Crises with Hypoacusis" "identificador" => "sec0045" ] 1 => array:4 [ "apendice" => "<p id="par0400" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Caused</span></p> <p id="par0405" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">By posture.</span> BPPV, with 2 possibilities:<ul class="elsevierStyleList" id="lis0075"><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">–</span><p id="par0410" class="elsevierStylePara elsevierViewall">Definitive BPPV, according to the prior definition of the classification: “known as benign paroxysmal positional vertigo and defined as a brief vertigo (usually lasting seconds), caused by positional triggering tests (Dix and Hallpike test, lateral position test, rotation test or cephalic hyperextension test) which is finite and reproducible”.</p></li><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">–</span><p id="par0415" class="elsevierStylePara elsevierViewall">Probable BPPV: clinical manifestations suggestive of BPPV, but with negative positional tests at the time of consultation (due to spontaneous resolution of symptoms).</p></li></ul></p> <p id="par0420" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pressure-induced vertigo: perilymphatic fistula</span>. Vertigo triggered by mechanical pressure generated by the patient (Valsalva manoeuvre), by the explorer (pressure generated in the external ear canal) or by sounds (Tullio phenomenon). Generally, perilymphatic fistulas appear with hearing loss; however, in superior semicircular canal dehiscence there may not be hearing loss.</p> <p id="par0425" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Spontaneous</span></p> <p id="par0430" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Vestibular migraine.</span><a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> Defined by 4 criteria:<ul class="elsevierStyleList" id="lis0080"><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">–</span><p id="par0435" class="elsevierStylePara elsevierViewall">Episodic vestibular symptoms of moderate intensity.</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">–</span><p id="par0440" class="elsevierStylePara elsevierViewall">Current or previous history of migraine according to ICHD-II criteria.</p></li><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">–</span><p id="par0445" class="elsevierStylePara elsevierViewall">One of the following migraine symptoms must occur during at least 2 vertigo crises: migrainous headache, photophobia, phonophobia, visual symptoms or other auras.</p></li><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">–</span><p id="par0450" class="elsevierStylePara elsevierViewall">Other causes must be ruled out by appropriate laboratory tests.</p></li></ul></p> <p id="par0455" class="elsevierStylePara elsevierViewall">Vestibular symptoms include rotatory vertigo or another illusion of bodily or object movement, which can be spontaneous or positional. Vestibular symptoms are “moderate” if they interfere with, but do not prevent daily activities.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The diagnosis of vestibular migraine does not require consistent association between vertigo and headache. In fact, this systematic association only occurs in 5%–10% of patients who meet the criteria for vestibular migraine. Typically, migraine headaches often precede the vertigo crises by several years.</p> <p id="par0460" class="elsevierStylePara elsevierViewall">In any case, although widely used and studied, the term vestibular migraine is not included in ICHD.</p> <p id="par0465" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Metabolic vertigo</span>. Balance disorder (instability and/or episodes of movement sensation) in patients with known metabolic and unbalanced diseases (diabetes, kidney disease, etc.). The symptoms should be reversed once the metabolic symptoms are balanced.</p> <p id="par0470" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Paroxysmal vertigo of childhood</span>. Brief and recurrent episodes (less than 15 min) of loss of balance which appear during the first years of life (usually before the age of 6 years). It can be accompanied by vegetative symptoms and tend to disappear spontaneously (usually before the age of 10 years). It is often associated with migraine.</p> <p id="par0475" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Vertigo of vascular origin (TIA, vertebrobasilar insufficiency</span>). Repeated episodes of vertigo or imbalance in elderly patients and/or those with cardiovascular risk factors, sometimes triggered by sudden movements of the cervical region. Accompanied by transient symptoms of posterior fossa ischemia (blurred vision and/or photopsia, occipital headache, loss of strength and/or paresthesias in upper limbs, etc.) with complete recovery after the crises.</p> <p id="par0480" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic"><span class="elsevierStyleBold">Vertigo of unknown origin</span></span>. Referring to vertigos which could not be included in any of the above sections.</p>" "etiqueta" => "A.2.2" "titulo" => "Recurrent Vertigo Crises Without Hypoacusis" "identificador" => "sec0050" ] ] ] ] ] ] ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1313 "Ancho" => 1991 "Tamanyo" => 77904 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Diagnostic agreement (agreement between at least 4 reviewers).</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="middle" style="border-bottom: 2px solid black">Patients With Positive Diagnosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="middle" style="border-bottom: 2px solid black">Patients With Vertigo of Undetermined Origin \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="middle" style="border-bottom: 2px solid black">Patients Not Included in the Classification \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Evaluator 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">38 (76%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">12 (24%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Evaluator 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">29 (58%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">10 (20%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">11 (22%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Evaluator 3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">26 (52%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">1 (2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">23 (46%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Evaluator 4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">27 (54%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">14 (28%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">9 (18%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Evaluator 5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">32 (64%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">5 (10%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">13 (26%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Evaluator 6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">29 (58%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">21 (42%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="middle">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab179738.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Patients Who Could or Could Not Be Included in the Classification.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">No agreement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">0–0.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Insignificant \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">0.2–0.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Low \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">0.4–0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Moderate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">0.6–0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Good \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">0.8–1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="middle">Very good \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab179739.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Degree of agreement, estimated according to kappa index result.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">TIA: transient ischemic attack; BPPV: benign paroxysmal positional vertigo.</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Patients with persistent or recurrent instability were not included in this classification.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Single vertigo crisis</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Acute vertigo with hypoacusis:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>– With cochlear involvement (labyrinthitis). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>– Cochleovestibular neuritis (Ramsay–Hunt syndrome). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Acute vertigo without hypoacusis (vestibular neuritis)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Recurrent vertigo crises</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Recurrent vertigo crises with hearing loss:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>– Ménière's disease. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>– Basilar-type migraine. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>– Autoimmune inner ear disease. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>– Neurosyphilis/otosyphilis. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>– Perilymphatic fistula. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Recurrent vertigo crises without hypoacusis:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>– Caused. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>– Caused by posture. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>– Definitive benign paroxysmal positional vertigo (definitive BPPV). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>– Probable benign paroxysmal positional vertigo (probable BPPV). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>– Pressure-triggered vertigo: perilymphatic fistulas. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>– Spontaneous. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>– Vestibular migraine. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>– Metabolic vertigo. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>– Paroxysmal vertigo of childhood. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>– Vertigo of vascular origin (TIA, vertebrobasilar insufficiency). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">Vertigo of undetermined origin</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab179740.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Diagnostic Categories for Peripheral Vestibular Disorder (SEORL-PCF 2011, Version 2).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => 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Newman-Toker" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3233/VES-2009-0343" "Revista" => array:6 [ "tituloSerie" => "J Vestib Res" "fecha" => "2009" "volumen" => "19" "paginaInicial" => "1" "paginaFinal" => "13" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19893191" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clasificación de los vértigos periféricos. Documento de Consenso de la Comisión de Otoneurología de la Sociedad Española de Otorrinolaringología (2003–2006)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Morera" 1 => "H. Pérez" 2 => "N. Pérez" 3 => "A. Soto" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Acta Otorrinolaringol Esp" "fecha" => "2008" "volumen" => "59" "paginaInicial" => "76" "paginaFinal" => "79" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18341864" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Relationship between basilar-type migraine and migrainous vertigo" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "C.T. Wang" 1 => "M.S. Lai" 2 => "Y.H. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 11 | 0 | 11 |
| 2024 September | 35 | 0 | 35 |
| 2024 August | 27 | 2 | 29 |
| 2024 July | 12 | 0 | 12 |
| 2024 June | 6 | 0 | 6 |
| 2024 May | 9 | 1 | 10 |
| 2024 April | 7 | 0 | 7 |
| 2024 March | 6 | 2 | 8 |
| 2024 February | 3 | 0 | 3 |
| 2024 January | 6 | 0 | 6 |
| 2023 December | 5 | 0 | 5 |
| 2023 November | 3 | 0 | 3 |
| 2023 October | 7 | 0 | 7 |
| 2023 September | 3 | 0 | 3 |
| 2023 August | 6 | 0 | 6 |
| 2023 July | 4 | 0 | 4 |
| 2023 June | 6 | 0 | 6 |
| 2023 May | 3 | 0 | 3 |
| 2023 April | 3 | 0 | 3 |
| 2023 March | 3 | 1 | 4 |
| 2023 January | 4 | 0 | 4 |
| 2022 December | 5 | 0 | 5 |
| 2022 November | 4 | 0 | 4 |
| 2022 October | 8 | 0 | 8 |
| 2022 September | 5 | 0 | 5 |
| 2022 August | 4 | 0 | 4 |
| 2022 July | 4 | 0 | 4 |
| 2022 June | 2 | 0 | 2 |
| 2022 May | 2 | 0 | 2 |
| 2022 April | 7 | 0 | 7 |
| 2022 March | 5 | 0 | 5 |
| 2022 February | 5 | 0 | 5 |
| 2022 January | 2 | 0 | 2 |
| 2021 November | 1 | 0 | 1 |
| 2021 March | 0 | 10 | 10 |
| 2021 February | 0 | 3 | 3 |
| 2021 January | 0 | 14 | 14 |
| 2020 December | 0 | 15 | 15 |
| 2020 November | 0 | 17 | 17 |
| 2020 October | 0 | 14 | 14 |
| 2020 September | 0 | 3 | 3 |
| 2020 August | 0 | 6 | 6 |
| 2020 July | 1 | 8 | 9 |
| 2020 June | 0 | 2 | 2 |
| 2020 May | 0 | 9 | 9 |
| 2020 April | 0 | 3 | 3 |
| 2020 March | 22 | 16 | 38 |
| 2020 February | 25 | 23 | 48 |
| 2020 January | 37 | 16 | 53 |
| 2019 December | 23 | 12 | 35 |
| 2019 November | 27 | 28 | 55 |
| 2019 October | 24 | 27 | 51 |
| 2019 September | 17 | 22 | 39 |
| 2019 August | 14 | 17 | 31 |
| 2019 July | 23 | 20 | 43 |
| 2019 June | 37 | 31 | 68 |
| 2019 May | 104 | 56 | 160 |
| 2019 April | 47 | 25 | 72 |
| 2019 March | 14 | 14 | 28 |
| 2019 February | 15 | 8 | 23 |
| 2019 January | 13 | 11 | 24 |
| 2018 December | 12 | 6 | 18 |
| 2018 November | 25 | 17 | 42 |
| 2018 October | 18 | 5 | 23 |
| 2018 April | 10 | 8 | 18 |
| 2018 March | 5 | 3 | 8 |
| 2018 February | 16 | 8 | 24 |
| 2018 January | 13 | 7 | 20 |
| 2017 December | 16 | 4 | 20 |
| 2017 November | 9 | 5 | 14 |
| 2017 October | 22 | 6 | 28 |
| 2017 September | 20 | 15 | 35 |
| 2017 August | 18 | 5 | 23 |
| 2017 July | 25 | 10 | 35 |
| 2017 June | 32 | 17 | 49 |
| 2017 May | 22 | 9 | 31 |
| 2017 April | 13 | 16 | 29 |
| 2017 March | 14 | 11 | 25 |
| 2017 February | 19 | 8 | 27 |
| 2017 January | 18 | 4 | 22 |
| 2016 December | 24 | 16 | 40 |
| 2016 November | 25 | 7 | 32 |
| 2016 October | 29 | 9 | 38 |
| 2016 September | 18 | 13 | 31 |
| 2016 August | 20 | 10 | 30 |
| 2016 July | 12 | 3 | 15 |
| 2016 June | 19 | 16 | 35 |
| 2016 May | 24 | 21 | 45 |
| 2016 April | 29 | 15 | 44 |
| 2016 March | 24 | 24 | 48 |
| 2016 February | 25 | 21 | 46 |
| 2016 January | 25 | 20 | 45 |
| 2015 December | 19 | 16 | 35 |
| 2015 November | 25 | 19 | 44 |
| 2015 October | 26 | 18 | 44 |
| 2015 September | 15 | 13 | 28 |
| 2015 August | 14 | 8 | 22 |
| 2015 July | 15 | 6 | 21 |
| 2015 June | 6 | 10 | 16 |
| 2015 May | 25 | 6 | 31 |
| 2015 April | 27 | 12 | 39 |
| 2015 March | 39 | 6 | 45 |
| 2015 February | 20 | 3 | 23 |
| 2015 January | 41 | 6 | 47 |
| 2014 December | 38 | 7 | 45 |
| 2014 November | 21 | 4 | 25 |
| 2014 October | 54 | 2 | 56 |
| 2014 September | 44 | 6 | 50 |
| 2014 August | 27 | 9 | 36 |
| 2014 July | 22 | 9 | 31 |
| 2014 June | 29 | 2 | 31 |
| 2014 May | 36 | 4 | 40 |
| 2014 April | 29 | 8 | 37 |
| 2014 March | 49 | 4 | 53 |
| 2014 February | 14 | 3 | 17 |
| 2014 January | 6 | 4 | 10 |
| 2013 December | 19 | 9 | 28 |
| 2013 November | 12 | 4 | 16 |
| 2013 October | 17 | 8 | 25 |
| 2013 September | 13 | 8 | 21 |
| 2013 August | 8 | 1 | 9 |
| 2013 July | 4 | 1 | 5 |
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