-
ARTICLE IN PRESS+ModelBraz J Otorhinolaryngol.
2015;xxx(xx):xxx---xxx
www.bjorl.org
Brazilian Journal of
OTORHINOLARYNGOLOGY
ORIGINA
Hyperrecurrvertigo
GuilhermJos DioAna Lvi
a Hospital db Escola Pau
Received 13
KEYWOVertigo;Glucose disorderCarbohymetabolDizzines
Please csulinemia ahttp://dx.d Institut Correspo
E-mail: g
http://dx.d1808-8694/reserved.e Webstera,, Patrcia Maria Sensa,
Mrcio Cavalcante Salmitob,go Rijo Cavalcantea, Paula Regina
Bonifcio dos Santosa,a Muniz da Silvaa, rica Carla Figueiredo de
Souzaa
o Servidor Pblico Municipal de So Paulo (HSPM), So Paulo, SP,
Brazillista de Medicina, Universidade Federal de So Paulo
(EPM/UNIFESP), So Paulo, SP, Brazil
August 2014; accepted 14 September 2014
RDS
metabolisms;drateism;s
AbstractIntroduction: Changes in carbohydrate metabolism may
lead to recurrence of benign paroxys-mal positional
vertigo.Objective: To evaluate the inuence of the disturbance of
carbohydrate metabolism in therecurrence of idiopathic
BPPV.Methods: A longitudinal prospective study of a cohort, with 41
months follow-up. We analyzedthe results of 72 glucose---insulin
curves in patients with recurrence of BPPV. The curves wereclassied
into intolerance, hyperinsulinemia, hyperglycemia and
normal.Results: The RR for hyperinsulinism was 4.66 and p = 0.0015.
Existing hyperglycemia showedan RR = 2.47, with p = 0.0123. Glucose
intolerance had a RR of 0.63, with p = 0.096. When theexamination
was within normal limits, the result was RR = 0.2225 and p =
0.030.Discussion: Metabolic changes can cause dizziness and vertigo
and are very common in peoplewho have cochleovestibular disorders.
However, few studies discuss the relationship betweenidiopathic
BPPV and alterations in carbohydrate metabolism. In the present
study, we found thatboth hyperglycemia and hyperinsulinemia are
risk factors for the recurrence of BPPV, whereas anormal test was
considered a protective factor; all these were statistically
signicant. Glucoseintolerance that was already present was not
statistically signicant in the group evaluated.
ite this article as: Webster G, Sens PM, Salmito MC, Cavalcante
JD, dos Santos PR, da Silva AL, et al. Hyperin-nd hypoglycemia:
risk factors for recurrence of benign paroxysmal positional
vertigo. Braz J Otorhinolaryngol.
2015.oi.org/10.1016/j.bjorl.2014.09.008ion: Hospital do Servidor
Pblico Municipal de So Paulo, So Paulo, SP, Brazil.nding
[email protected] (G. Webster).
oi.org/10.1016/j.bjorl.2014.09.008 2015 Associaco Brasileira de
Otorrinolaringologia e Cirurgia Crvico-Facial. Published by
Elsevier Editora Ltda. All rights
BJORL-144; No. of Pages 5L ARTICLE
insulinemia and hypoglycemia: risk factors forence of benign
paroxysmal positional,
-
ARTICLE IN PRESS+Model2 Webster G et al.
Conclusion: Hyperinsulinemia and hyperglycemia are risk factors
for the recurrence of idio-pathic BPPV and a normal exam is
considered a protective factor. 2015 Associaco Brasileira de
Otorrinolaringologia e Cirurgia Crvico-Facial. Published byElsevier
Editora Ltda. All rights reserved.
PALAVRVertigemTranstormetabolglucose;MetabolicarboidrTontura
fator
ismo
rbiooortglicoadas
RR = a g
odes coa e aa, quxamtoler
Introduc
Benign posthe most coand is classpredomina50---60 yearaged over
BPPV in the
In mostIn secondatraumatic brobasilar disease.6 Hchanges wcause
of se
Numerocochleovesdrate metahave beendisorders.8
In carbglucose, socally hyperAS-CHAVE;nos doismo de
smo dosatos;
Hiperinsulinismo e hiperglicemia: postural paroxstica
benigna
ResumoIntroduco: As alteraces do metaboltigem posicional
paroxstica benigna.Objetivo: Avaliar a inuncia dos distMtodo:
Estudo longitudinal, do tipo cAnalisaram-se 72 resultados de curvas
cia de VPPB. As curvas foram classicnormal.Resultados: O
hiperinsulinismo teve RR = 2,47 e p = 0,0123. Na intolernciaRR =
0,2225 e p = 0,030.Discusso: As alteraces metablicas pna populaco
que apresenta distrbiosobre a relaco entre a VPPB
idiopticvericou-se que tanto a hiperglicemirecorrncia de VPPB, ao
passo que o eestatisticamente signicantes. J a ingrupo
avaliado.
Concluso: O hiperinsulinismo e a hiperglirecorrncia de VPPB
idioptica, assim com 2015 Associaco Brasileira de
OtorrinolaElsevier Editora Ltda. Todos os direitos rese
tion
tural (or positional) paroxysmal vertigo (BPPV) ismmon cause of
dizziness in the adult population,ied as a peripheral vestibular
syndrome.1---3 BPPVtes in females and in those aged greater thans.
In addition, approximately 30% of the elderly70 years will
experience at least one episode ofir lives.4,5
cases, the patient suffers from idiopathic BPPV.ry BPPV, some
causes have been found, such as:brain injury, post-operative ear
surgery, verte-insufciency, vestibular neuronitis and Mniresowever,
few studies have related metabolic
ith BPPV, or even identied such changes as acondary BPPV.7
us metabolic disorders can affect thetibular apparatus.8---12
Changes in carbohy-bolism, more precisely in glucose
metabolism,
associated with frequent causes of inner ear---12
ohydrate disorders, especially those affectingme authors propose
that, in patients with chroni-glycemic diabetes mellitus, the
histopathological
changes ofpresent.11,
larization compromissupply to t
The posYoda et al.litus exhibcoming froaddition, ttion of
sucyears of ilin patientsobserved awith BPPV lence in pe
In the liand 30%.1,1
opment of of BPPV.1,1
not there iThe aim
of carbohyBPPV.es de risco para recorrncia de vertigem
do carboidrato podem levar a recorrncia de ver-
s do carboidrato na recorrncia da VPPB idioptica.e, prospectivo,
com 41 meses de acompanhamento.insulinmicas em pacientes portadores
de recorrn-
em intolerncia, hiperinsulinemia, hiperglicemia e
4,66 e p = 0,0015. A hiperglicemia apresentou umlicose o RR =
0,63 e p = 0,096. No exame normal, o
m causar tontura e vertigem e so muito
frequentescleovestibulares. Contudo, poucos trabalhos falams
alteraces nos carboidratos. No presente estudo,anto o
hiperinsulinismo so fatores de risco para
e normal foi considerado fator protetor, todos estesncia glicose
no teve signicncia estatstica nocemia se comportam como fatores de
risco para ao o exame normal como um fator protetor.ringologia e
Cirurgia Crvico-Facial. Publicado porrvados.
microangiopathy and peripheral neuropathy are13 Considering that
the inner ear receives vascu-through terminal branches, such
changes mighte vestibular function, due to a decreased bloodhis
organ.t-mortem study of temporal bones performed by10 found that
patients with type 1 diabetes mel-it a much higher prevalence of
otocone debrism the utricle, compared to healthy patients. Inhese
authors found that the prevalence of migra-h debris also was
increased, in proportion to thelness. Thus, there is a greater
chance of BPPV
with type 1 diabetes mellitus. Cohen et al.14
20% prevalence of diabetes mellitus in patientsaged between 65
and 74 years, and a 43% preva-ople over 75 years.terature,
recurrence of BPPV varies between 20%5 Several factors have been
linked to the devel-recurrence, including age, gender, and
etiology
5 However, it still remains uncertain whether ors a correlation
with metabolic disorders.
of this study was to evaluate the inuencedrate disorders in the
recurrence of idiopathic
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ARTICLE IN PRESS+ModelHyperinsulinemia and hypoglycemia: risk
factors for recurrence of VPPB 3
Methods
This study was approved by the Ethics Committee of thehospital
whnumber 06
This is acal recordsparoxysmaogy outpattertiary hoMay 2013.
those case
Patientspositional clinic untiasymptomarequested
Patientsvertigo or wBPPV, as wto follow-urequired ttreatment
secondary brain injuroperative were also e
All cliniregistered ment of Otcollected t
A survenosis of Bclinic, Otolclinical rediagnosis.
Recurretively and qclinical pictional nyst(RM), withtest, but
wby an ENTRM repetitFinally, patpear whenotolaryngoIt must beBPPV
wereHallpike m
The resand classi(ADA) critethe insulinby Kraft (1into four
ginsulin curimpaired gcalled pre-and patienare called dthe
recurre
Normal test
Normal test
ormal test
Abnormal test Abnormal test
normal test
Recurrent
Recurrent
No recurrence
No recurrence
Normal glucose-insulin curve
40.00%
50.00%
23.61% 4.17%31.94%40.28%
1 Distribution of patients with BPPV recurrence,ing
glucose---insulin tests within normal limits.
Chthe olismleve
ts
studsma09 tts wejectnd iformical fpathts, w
a ntive
a ose---
a re. 3),
a r. 4),
Glucose intolerance
No recurrence .00%
43.06%20.83% 8.33%
27.78%
.00%
.00%
.00%
No recurrence
Recurrent
Recurrent
Normal testNormal test
rmal test
Abnormal test Abnormal test
normal test
2 Distribution of patients with BPPV recurrence,ing tests with
glucose intolerance.ere it was conducted, according to CAEE
protocol181512.2.0000.5442.
longitudinal cohort study, which evaluated medi- of patients
with an objective diagnosis of benignl positional vertigo
established by the otoneurol-ient clinic of the Otolaryngology
Department of aspital during the period from December 2009 toThis
diagnosis was reviewed more than once ins where recurrence of the
disease occurred.
with objective idiopathic benign paroxysmalvertigo monitored in
the otoneurology outpatientl their discharge (which occurred only
after antic period of 6 months), and who submitted to a3-h glucose
tolerance test were included.
with subjective benign paroxysmal positionalith other causes of
dizziness not associated withell as patients who discontinued or
were lostp before discharge, those failing to make the
ests, or patients with a previous diagnosis andfor BPPV were
excluded. Patients diagnosed withBPPV of undetermined etiology,
such as traumaticy, Mnires disease, vestibular neuronitis, post-of
ear surgery, and vertebrobasilar insufciencyxcluded.cal records of
patients with a diagnosis of BPPVat the otoneurology outpatient
clinic, Depart-olaryngology, were surveyed. In these charts, wehe
relevant data at diagnosis.y of the records of all patients who had
a diag-PPV registered at the otoneurology outpatientaryngology
Department, was conducted. In thesecords, all data were obtained at
the date of
nce of the disease was evaluated both qualita-uantitatively;
recurrence was dened as thatture in which disappearance of vertigo
and posi-agmus occurred after repositioning maneuvers
assessment by Dix-Hallpike maneuver and rollith return of these
signs and symptoms veried
physician within six months of follow-up. Afterion, these
patients were again asymptomatic.ients whose nystagmus and vertigo
did not disap-
RM were carried out under the supervision of anlogist were
classied as having persistent BPPV.
emphasized that the recurrences of episodes of evaluated through
anamnesis and also by Dix-aneuver and roll test.ults of the
glycemic curve test were analyzeded according to American Diabetes
Associationria published in 2013, and the interpretation ofemic
curve was based on those criteria proposed975).14,15 Therefore, our
patients were classiedroups, according to the results of their
glucose-ves: patients with a normal test, patients withlucose
tolerance (who, according to ADA, arediabetic patients), patients
with hyperinsulinism,ts with hyperglycemia (who, according to
ADA,iabetics); in these patients, the relationship withnce of BPPV
was evaluated.
NAb
0.00%
10.00%
20.00%
30.00%
Figureregard
Thetively metabcance
Resul
In thisparoxyber 20patiening subnot fouing perof clinas
idiopatien
Withrela
Withgluc
With(Fig
With(Fig
0
20
40
60
NoAb
Figureregardi-squared test was used to assess
quantita-relationship between changes in carbohydrate
and rate of recurrence. The statistical signi-l was set at p =
0.05.
y, 103 medical records of patients with benignl positional
vertigo during the period from Decem-o May 31, 2013 were evaluated.
Of these, 31re excluded from the study (11 patients for hav-ive
BPPV; 5 patients whose medical records weren the hospital medical
le; 7 patients for not hav-ed the required tests and/or for
discontinuationollow-up; and 8 patients for not being consideredic
cases). Thus, the nal number of cases was 72hose sample was divided
as follows:
ormal result in glucose---insulin tests (Fig. 1), arisk (RR) of
0.2225 was found, with p = 0.03054.
result of impaired glucose tolerance ininsulin tests (Fig. 2),
RR = 0.6315, p = 0.096.sult of hyperinsulinemia in
glucose---insulin testsRR = 4.6647, p = 0.0015.esult of
hyperglycemia in glucose---insulin testsRR = 2.4761, p =
0.0123.
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ARTICLE IN PRESS+Model4 Webster G et al.
Hyperinsulinemia
0.00%
20.00%
40.00%
60.00%
Abnormal test Abnormal test
Abnorm
Normal test
Normal test
Norma
Figure 3 regarding te
NormaAbnorm
0.00%
20.00%
40.00%
60.00%
Figure 4 regarding te
Discussio
Dizziness iseral populaaffects mointerfere welderly losviduals,
whAn importafalls, especeffects areple died frterms of puin the
elde
Althouga recognizdominantlyconducted BPPV and ence the
dpictures.
There isassociated a causal rehistopathocan act asfunction,
avestibular
We didwith glucorecurrencemay sugge
metabolism is not signicant to the point of an associationwith
the evolution of BPPV. However, no theories can beproposed until a
larger number of patients with impairedglucose tolerance and also
with BPPV have been evaluated.
On the other hand, the presence of hyperinsulinismgatinic
ahichial t8,9 Fchanr of
ed oolismsmasuchhighepulapergecurpatief onavingenceimotof
BPerinocias, wm wos --- encetherof beeconent,No recurrence
43.06%20.83%
11.11%
25.00%
No recurrence
Recurrent
Recurrent
al test l test
Distribution of patients with BPPV recurrence,sts with
hyperinsulinemia.
Hyperglicemia
No recurrence
No recurrence
Recurrent
Recurrent
Normal test
Normal test
l test
Abnormal test Abnormal test
al test 54.17%9.72%
25.00%
11.11%
Distribution of patients with BPPV recurrence,sts with
hyperglycemia.
n
a major limiting factor in the daily life of the gen-tion, with
exacerbation in the elderly because itvements of those who
experience it, and it canith domestic and even social activities.16
The
e their autonomy and become dependent indi-
can nethe iolaris, wpotentspace.small numbesac.11
Basmetabparoxytions, times eral pothe hyBPPV rhand, a RR othat
hrecurr
Tanrence Considthe asshydropsulinishydroprecurr
Furrence with sstatemich further decreases their quality of
life.17---20
nt consequence of dizziness is the occurrence ofially for those
over 60 years of age, because the
even more severe.4 In Brazil, 6802 elderly peo-om falls in the
year 201021 --- an alarming fact inblic health. This can be partly
explained by BPPVrly.4
h benign paroxysmal positional vertigo has beened entity for
decades, its etiology remains pre-
idiopathic.6,22,23 However, few studies have beenwith the aim to
clarify the relationship betweenother comorbidities, and how they
could inu-isease severity and the prognosis of these clinical
good evidence that metabolic disorders can bewith
BPPV7,8,9,10,11,12 but it is difcult to conrmlationship, since it
is impossible to observe thelogical changes in vivo. These
metabolic disorders
a principal etiological factor in vestibular dys-s well as an
aggravating factor of a pre-existingdisorder.9
not nd statistical signicance for patientsse intolerance in
relation to the number ofs, compared to normal subjects. This
ndingst that this degree of change in carbohydrate
it possiblesecondary
Conclusi
Glucose mrence in thboth hypertors for recglucose tol
Conicts
The author
Referenc
1. Perez P,Recurrenrotol. 20
2. Balatsoutiple canvely impact inner ear hemostasis, as a
result ofnd metabolic characteristics of the stria vascu-
is responsible for maintaining the endocochlearhrough potassium
secretion into endolymphaticurthermore, the labyrinth is very
sensitive toges in plasma insulin levels, due to the large
insulin receptors present in the endolymphatic
n these suggestive signs (i.e., that glucose may be associated
to clinical pictures of benign
l positional vertigo), this study found some rela- as: the
hyperinsulinemic patient has a RR 4.6r for BPPV recurrence,
compared with the gen-tion --- a statistically signicant nding.
Likewise,lycemic patient has a RR 2.47 times higher forrence, also
statistically signicant. On the othernts with a normal
glucose---insulin curve test havely 0.22, also statistically
signicant. This means
a normal value may be a protective factor for of BPPV.o et al.24
found that the only risk factor for recur-PV was the presence of
endolymphatic hydrops.
g that the literature is pretty consistent regardingtion between
hyperinsulinism and endolymphatice can call into question whether,
in fact, hyperin-uld not be an underlying event to
endolymphaticthis latter being the actual risk factor for those
values found by the author in his series.more, Tanimoto et al.24
reported that the recur-nign paroxysmal positional vertigo was
associateddary causes, more than to idiopathic BPPV. This
combined with the results of our study, makes to propose the
hypothesis of a form of BPPVto glucose metabolism disorders.
on
etabolism disorders are related to BPPV recur-e group evaluated.
In this study, we found thatinsulinism and hyperglycemia behaved as
risk fac-urrence of idiopathic BPPV, and also that a normalerance
test acted as a protective factor.
of interest
s declare no conicts of interest.
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Hyperinsulinemia and hypoglycemia: risk factors for recurrence
of benign paroxysmal positional
vertigoIntroductionMethodsResultsDiscussionConclusionConflicts of
interestReferences
