SPIN - Issue 99 (2019)

SPIN 99 © 2018 The Ménière’s Society 5 Articles and Features Dr Peter Savundra, Audiovestibular Physician, The Portland Hospital, London Conference Report Persistent Postural-Perceptual Dizziness Persistent postural-perceptual dizziness (Triple PD) is a diagnosis recently recognised by the Barany Society, the international committee which has oversight on vestibular issues. Although the diagnostic term is new, the symptoms of Triple PD have long been known to many people with Ménière’s. The biological change underpinning Ménière’s is endolymphatic hydrops, but one of the two Ménière’s patients studied by Dr Charles Hallpike, the discoverer of endolymphatic hydrops in 1938, may well have had Triple PD. The priority in the management of Ménière’s is, of course, to reduce the frequency and severity of the attacks and if possible to eliminate them. There are medical and surgical fixes. It is also important to manage the persistent almost daily symptoms some people with Ménière’s experience. To do this it is important to have precise diagnostic labels so that a personalised package of treatment can be offered. Triple PD is present in people with dizziness, unsteadiness and non-spinning vertigo for most days over a three month period (Box 1). Therefore, the symptoms of Triple PD are different from the symptoms in attacks of Ménière’s. The symptoms of Triple PD can be exacerbated by change of posture, by movement, by visual stimuli, by fatigue and by stress. Box 1 The Symptoms of Triple PD  Dizziness  Unsteadiness  Non-spinning vertigo  Most days over a three month period  Aggravated by movement, posture, visual stimuli, fatigue and stress All the symptoms we experience are underpinned by brain processing. This is why two people with identical ear damage can have very different symptoms and lead very different lives. Vestibular symptoms impair cognitive function and affect mood because of their impact on brain processing. Vestibular dysfunction causes imbalance because of the impairment of activation of the antigravity muscles. The healthy brain has a built-in tendency to use vision for balance, but this wastes brain resources. So the targets of treatment in Triple PD (Box 2) are to free up the brain to carry out the clever tasks it is meant to do, to re-activate Box 2 Targets of Treatment of Triple PD  Free the brain to do its proper job  Activate the antigravity muscles  Reduce the over reliance on visual cues