Comments on the Symptom of “Dizziness” and Vestibular Science

LETTER TO THE EDITOR C o m m e n t s on the Symptom of "Dizziness" a n d Vestibular Science To the Editor: I want to congratulate you on publishing, and the NIH and NIDCD for supporting, the Conference on Clinical Applications of Vestibular Science that appeared in the January 1995 issue of the JOURNAL I would like to comment on several of the articles. Dr. Baloh describes (p. 3) the symptoms in vestibular dizziness as a feeling of spinning or as of being drunk or having motion sickness, and those of nonvestibular dizziness as feelings of "lightheaded[ness]," "floating," "gidd[iness]," or "swimming." The problem is that "drunk" symptoms are often described as lightheadedness, floating, giddiness, and swimming. The conclusion is that Dr. Baloh's nonvestibular symptoms may well be vestibular. McNally and Stuart, 1 in their classic paper, report that patients described such sensations as faintness, unsteadiness, rocking, staggering, swimming, weakness, waviness, and backward swaying after caloric stimulation. The conclusion is that Dr. Baloh's "nonvestibular" symptoms can be vestibular. My experience as a clinician and patient is that these nonspinning symptoms are usually vestibular and that they fall into the diagnostic categories of metabolic disorders as described by Dr. Rybak in his paper at this conference (pp. 128-132), the perilymphatic fistula syndrome, and most commonly, the nucleoreticular vestibular syndrome described by Arslan and Sala 2 and Bosatra, 3 a syndrome that has not yet received recognition in this country. There are only symptoms in those with pure metabolic disorders, but there are findings of mild dysequilibrium in the latter two conditions. I am currently experiencing the unique opportunity of being afflicted with nucleoreticular vestibular syndrome, a condition that I have described. 4,5 I can testify to the lightheaded sensation that made me feel weak and faint at the onset, which occurred while I was standing at the sink in the evening. It recurs on head movement, especially bending, and on getting out of bed at night, at which time I stagger, on a broad base, as I make my way to the bathroom. It also occurs on returning to bed and on rolling over, indicating that it is not due to cerebral ischemia, as postulated by Baloh in his chart on page 4 of the JOURNAL. I am improving, as regards the imbalance and lightheadedness, with azatadine, an antiserotonin drug that I routinely use when I treat this condition, which is diagnosed on the basis of the history, a finding of imbalance on t h e Quix test, and a finding of abnormality in the brain stem on suprathreshold stapedius muscle reflex testing, all of which are described in the referenced papers. Dr. Honorubia is to be applauded for his role in advancing vestibular science and in presenting that sci168 Otolaryngology-Head and Neck Surgery

ence to the community of clinicians and scientists in this conference. In his introduction (p. 2) he describes the need for reciprocal information to advance necessary research and wishes to address the needs of clinicians and researchers. In the summary of his article (pp. 64-75) he recognizes the shortcomings of the present vestibular tests but expects that they will ultimately be tailored for the evaluation of "well-defined" vestibular disorders. The problem is that defining vestibular disorders is a clinical task, performed by clinicians practicing the "art" of medicine. The empirical approach, which Dr. Honrubia decries in his opening paragraph (p. 64), is the clinical approach, one based on observation and experience. It is not only compatible with rational science but can be helpful in the development and testing of theories. Dr. Joshua Lederberg, a Nobel laureate, in a talk that I attended, described the clinical description of a familial genetic defect as a crucial piece of information in the unraveling of the functions of DNA. Rational science also depends on observation to confirm hypotheses and theories. Paul Johnson describes Einstein as "an empirical scientist of the most rigorous kind, formulating his theories specifically to make exact verification possible, and insisting it take place before according his views any validity.''6 The clinician (the empiricist) practicing the art of medicine and the rational scientist (who uses empiric proofs of theories) must work together for the good of our patients and our profession. Once again, let me thank the JOURNAL,the NIH, and the NIDCD and Dr. Honrubia for arranging and presenting this most important conference. Joel F. Lehrer, MD Northern Jersey Ear, Nose, and Throat Association 315 Cedar Ln. Teaneck, NJ 07666

23/8/65116 REFERENCES 1. McNally NJ, Stuart EA. Vertigo from the standpoint of the otolaryngologist. Trans Am Acad Ophthalmol Otol 1941;46: 33-7. 2. Arslan M, Sala O. Fisiopatalogia e clinica delle vie vestibolari centrali. Atti del 44 Congress0 Soc Ital Lar Otol, Bologna, Italy, 1956. 3. Bosatra A. Contributo alla conoscenza della sindrome vestibolare nucleo-reticolare. Arch Ital Otol Rin Laringol 1978;6: 181-6. 4. Lehrer JF, Poole DC. Diagnosis and management of vertigo. Compr Ther 1987;13(9):31-40. 5. Lehrer JF, Poole DC. Vestibular neuronitis dissected into vestibular neuritis and the nucleo-reticular vestibular syndrome. In: Arenberg IK, ed. Surgery of the inner ear. Amsterdam: Kugler Publications, 1991:431-6. 6. Johnson P. A history of the Jews. New York: Harper and Row, 1987:418. January 1996