Multiple positional nystagmus suggests multiple canal involvement in benign paroxysmal vertigo

CONCLUSION: Video-oculography demonstrates a higher occurrence of atypical positional nystagmus in patients with benign paroxysmal positional vertigo (BPPV). This includes anterior and horizontal canal variants and multiple positional nystagmus, suggesting combined lesions affecting several canals. OBJECTIVE: To analyse the video-oculographic findings of positional tests in patients with BPPV. MATERIAL AND METHODS: Seventy individuals with symptoms of BPPV and positional nystagmus were included in this study. The diagnosis was based on a history of brief episodes of vertigo and the presence of positional nystagmus as confirmed by video-oculographic examination during the Dix-Hallpike test, the McClure test or the head-hanging manoeuvre. Patients were treated by means of different particle repositioning manoeuvres according to the affected canal (Epley's manoeuvre for the posterior or anterior canals and Lempert's manoeuvre for the lateral canal) and the effectiveness was evaluated at 7 and 30 days. RESULTS: Twenty-nine individuals (41.43%) presented an affected unilateral posterior canal. Fifteen patients (21.43%) presented a pure horizontal direction-changing positional nystagmus consistent with a diagnosis of horizontal canal BPPV. Twelve individuals (17.14%) presented a unilateral down-beating nystagmus, suggesting possible anterior canal BPPV. In addition, 14 patients (20%) showed multiple positional nystagmus during the examination corresponding to simultaneous multi-canal BPPV, 5 had bilateral posterior canal BPPV and 2 presented a positional down-beating nystagmus in both left and right Dix-Hallpike manoeuvres and the head-hanging manoeuvre, which is highly suggestive of anterior canal BPPV. However, seven individuals showed positional horizontal and vertical side-changing nystagmus that could not be explained by single-canal BPPV. These patients with multiple positional nystagmus showed changing patterns of positional nystagmus at follow-up.     

Benign paroxysmal positional vertigo due to a simultaneous involvement of both horizontal and posterior semicircular canals

From April 2001 to November 2003, we investigated 8 patients with benign paroxysmal positional vertigo (BPPV) that was suspected to simultaneously affect both the horizontal and posterior semicircular canals (HSCC and PSCC). These cases showed typical vertical-torsional nystagmus induced by the Dix-Hallpike maneuver, followed by a horizontal nystagmus. They also showed a direction-changing geotropic or apogeotropic positional nystagmus triggered by lateral head rotations in the supine position. Using the three-dimensional analysis of the positional nystagmus, the rotation axis of the positional nystagmus had a component perpendicular to the plane of PSCC and another component perpendicular to the plane of HSCC. All these findings suggest that BPPV in these patients was a combination of posterior and horizontal canal BPPV. The observation of a vertical-torsional positional nystagmus should prompt the specialist to perform not only the canalith repositioning procedure, but also to execute lateral head turns in the supine position.     

Multiple positional nystagmus suggests multiple canal involvement in benign paroxysmal positional vertigo

Conclusion. Video-oculography demonstrates a higher occurrence of atypical positional nystagmus in patients with benign paroxysmal positional vertigo (BPPV). This includes anterior and horizontal canal variants and multiple positional nystagmus, suggesting combined lesions affecting several canals. Objective. To analyse the video-oculographic findings of positional tests in patients with BPPV. Material and methods. Seventy individuals with symptoms of BPPV and positional nystagmus were included in this study. The diagnosis was based on a history of brief episodes of vertigo and the presence of positional nystagmus as confirmed by video-oculographic examination during the Dix–Hallpike test, the McClure test or the head-hanging manoeuvre. Patients were treated by means of different particle repositioning manoeuvres according to the affected canal (Epley's manoeuvre for the posterior or anterior canals and Lempert's manoeuvre for the lateral canal) and the effectiveness was evaluated at 7 and 30 days. Results. Twenty-nine individuals (41.43%) presented an affected unilateral posterior canal. Fifteen patients (21.43%) presented a pure horizontal direction-changing positional nystagmus consistent with a diagnosis of horizontal canal BPPV. Twelve individuals (17.14%) presented a unilateral down-beating nystagmus, suggesting possible anterior canal BPPV. In addition, 14 patients (20%) showed multiple positional nystagmus during the examination corresponding to simultaneous multi-canal BPPV, 5 had bilateral posterior canal BPPV and 2 presented a positional down-beating nystagmus in both left and right Dix–Hallpike manoeuvres and the head-hanging manoeuvre, which is highly suggestive of anterior canal BPPV. However, seven individuals showed positional horizontal and vertical side-changing nystagmus that could not be explained by single-canal BPPV. These patients with multiple positional nystagmus showed changing patterns of positional nystagmus at follow-up.     

A novel maneuver for diagnosis and treatment of torsional-vertical down beating positioning nystagmus: anterior canal and apogeotropic posterior canal BPPV

IntroductionIn patients with benign paroxysmal positional vertigo, BPPV; a torsional-vertical down beating positioning nystagmus can be elicited in the supine straight head-hanging position test or in the Dix-Hallpike test to either side. This type of nystagmus can be explained by either an anterior canal BPPV or by an apogeotropic variant of the contralateral posterior canal BPPV Until now all the therapeutic maneuvers that have been proposed address only one possibility, and without first performing a clear differential diagnosis between them.ObjectiveTo propose a new maneuver for torsional-vertical down beating positioning nystagmus with a clear lateralization that takes into account both possible diagnoses (anterior canal-BPPV and posterior canal-BPPV).MethodsA prospective cohort study was conducted on 157 consecutive patients with BPPV. The new maneuver was performed only in those with torsional-vertical down beating positioning nystagmus with clear lateralization.ResultsTwenty patients (12.7%) were diagnosed with a torsional-vertical down beating positioning nystagmus. The maneuver was performed in 10 (6.35%) patients, in whom the affected side was clearly determined. Seven (4.45%) patients were diagnosed with an anterior canal-BPPV and successfully treated. Two (1.25%) patients were diagnosed with a posterior canal-BPPV and successfully treated with an Epley maneuver after its conversion into a geotropic posterior BPPV.ConclusionThis new maneuver was found to be effective in resolving all the cases of torsional-vertical down beating positioning nystagmus-BPPV caused by an anterior canal-BPPV, and in shifting in a controlled way the posterior canal-BPPV cases of the contralateral side into a geotropic-posterior-BPPV successfully treated during the followup visit. Moreover, this new maneuver helped in the differential diagnosis between anterior canal-BPPV and a contralateral posterior canal-BPPV.     

Intermittent positional downbeat nystagmus of cervical origin

Intermittent positional down beat nystagmus (p-DBN) is rare. We describe an unusual case of intermittent p-DBN which was induced by rotation, anteflexion, and lateral flexion of the neck. A 59-year-old man complained of loss of consciousness and lightheadedness. Positional testing revealed the p-DBN. The evoked p-DBN had latency and the patient had a feeling of passing out while the p-DBN was present. There were no abnormal findings in the vestibular functional examinations. Findings of the MRI were negative. MRA revealed no stenosis of the vertebral artery bilaterally, but there was an anatomical difference. The p-DBN characteristics were documented by electronystagmography during the positional test. The p-DBN lasted intermittently while maintaining the provoking position. It was found that p-DBN occurred with not only the rotation of the neck, but also in the anteflexion and lateral flexion of the neck. There was no stenosis of the vertebral artery (VA) on angiography, but we speculated that the cause of the p-DBN was the VA occlusion due to rotation, anteflexion, and lateral flexion of the neck.     

以持续性眩晕为表现的水平半规管良性阵发性位置性眩晕的诊治

目的　探讨以持续性眩晕为表现的良性阵发性位置性眩晕（benign paroxysmal positional vertigo,BPPV）患者的诊治。方法　回顾性分析2例以持续性眩晕为表现的BPPV患者的临床资料。结果　此2例患者在坐位及平躺位见方向向患侧的水平自发持续性眼震,甩头试验健侧阳性,平卧侧头试验双侧均诱发出水平离地性眼震,平躺后头部向患侧连续转360°时分别出现2个眼震消失点和2个眼震最强点,给予手法复位后患者眩晕症状缓解。结论　水平半规管BPPV患者偶可表现为持续性眩晕发作,其病因为壶腹嵴帽耳石症,临床表现与耳石重力因素和水平半规管空间位置相关。     

Persistent positional nystagmus

Involvement of the superior semicircular canal (SSC) in benign paroxysmal positional vertigo (BPPV) is rare. SSC BPPV is distinguished from the more common posterior semicircular canal (PSC) variant by the pattern of nystagmus triggered by the Dix-Hallpike position: down-beating torsional nystagmus in SSC BPPV versus up-beating torsional nystagmus in PSC BPPV. SSC BPPV may be readily treated at the bedside, which is a key component in excluding central causes of down-beating nystagmus. We present an unusual video case report believed to represent refractory SSC BPPV based on the pattern of nystagmus and the absence of any other central signs.     

上半规管良性阵发性位置性眩晕的诊断及治疗

目的探讨上半规管良性阵发性位置性眩晕（benign paroxysmal positional vertigo，BPPV）的诊断和治疗。方法回顾性分析了上半规管BPPV患者31例，并对所有患者采用管石复位法治疗后的效果进行评估。结果在Dix-Hallpike检查中，所有患者均诱发出垂直向下的眼震。22例（70．97％）患者一侧诱发出眼震，其中17例眼震伴有扭转成分，5例眼震不伴扭转成分。其余9例（29．03％）患者双侧诱发出现眼震，眼震伴有扭转成分的7例，其中2例眼震扭转方向指向同一侧，4例眼震的扭转方向不固定，1例患者仅一侧出现扭转成分。另外2例患者眼震不伴扭转成分。受累侧别明确诊断的19例（61．29％），其中11例为左侧上半规管受累，8例为右侧上半规管受累。受累侧别未明确诊断的12例（38．71％）。所有患者中，11例（35．48％）患者同时合并后半规管受累。对所有患者采取管石复位法治疗，21例（67．74％）痊愈，29例（93．55％）有效、2例（6．45％）无效。其中首次治愈14例（45．16％），平均治愈次数为1．71次。随访期间5例复发。结论上半规管BPPV临床中少见。在变位检查中，眼震的扭转成分较弱，临床中不易观察。在部分单侧上半规管BPPV患者中，双侧检查均能诱发眼震。管石复位法是治疗上半规管BPPV简单有效的手段。     

Surgical management for benign paroxysmal positional vertigo of the superior semicircular canal

Benign paroxysmal positional vertigo of the superior semicircular canal is a rare form of BPPV. It accounts for 1% to 3% of cases. The characteristic nystagmus is positional, down‐beating, with a torsional component elicited by the Dix‐Hallpike maneuver. Symptoms of superior semicircular canal BPPV often resolve spontaneously; however, it can be refractory to repositioning maneuvers. Surgical management is described for posterior semicircular canal BPPV. To date, however, there is only one reported case of surgical management for superior semicircular canal BPPV. Here we show video documentation of positional, down‐beating nystagmus and describe a case of superior semicircular canal BPPV requiring canal occlusion with successful resolution of symptoms. Laryngoscope, 125:1965–1967, 2015     

Anterior semicircular canal benign paroxysmal positional vertigo and positional downbeating nystagmus

PURPOSE: The aim of this study was to describe the clinical features and video-oculographic findings in patients with anterior semicircular canal benign paroxysmal positional vertigo (BPPV). MATERIALS AND METHODS: STUDY DESIGN: This is a prospective case series. SETTING: The study was set at an outpatient clinic in a general hospital. PATIENTS: Fourteen individuals with symptoms of BPPV and positional downbeating nystagmus (pDBN) were included in the study. The diagnosis was based on a history of brief episodes of vertigo and the presence of pDBN confirmed in the video-oculographic examination during Dix-Hallpike test (DH) or head-hanging maneuver. INTERVENTION: Patients were treated by particle repositioning maneuver and the effectiveness was evaluated at 7, 30, and 180 days posttreatment. The treatment was repeated up to 4 times if pDBN was persistent. MAIN OUTCOME MEASURES: The main outcome measure is the number of patients without pDBN at 30 and 180 days. RESULTS: Video-oculography showed a predominant pDBN in response to DH. Of the 14 patients, 7 had arterial hypertension, and 5 of 14 cases presented abnormalities on the caloric test. Horizontal spontaneous nystagmus was found in 3 of 14 individuals. Positional nystagmus at different positional test was observed in 5 of 14 individuals, suggesting the involvement of several canals. Of the 14 patients, 10 (71%) did not present vertigo, and the positional tests were negative at 30 days. However, 3 cases presented a positive DH with persistence of BPPV episodes and pDBN at 30 days, and another developed a contralateral posterior canal affectation. One of the patients maintained a persistent pDBN at 180 days despite the repeated maneuvers. CONCLUSIONS: Video-oculography demonstrates that anterior canal BPPV is characterized by a predominant downbeating nystagmus in response to DH. These individuals may show alterations in the vestibular caloric, and they can have multicanal affectation.     

Changes in slow phase eye velocity and time constant of positional nystagmus at transform from cupulolithiasis to canalolithiasis

Changes in slow phase eye velocity (SPEV) and time constant (TC) of benign paroxysmal positional nystagmus in horizontal canal type were examined at transitional period from cupulolithiasis (apogeotropic nystagmus) into canalolithiasis (geotropic nystagmus) in two patients. SPEV and TC of positional nystagmus were tri-dimensionally analyzed. The first patient showed an apogeotropic nystagmus. Head rotation to the left in supine position induced a right-beating nystagmus with an initial SPEV of 15.3°/s and a TC of 133 s. The nystagmus then gradually declined with a TC of 31.3 s after reaching a maximum SPEV of 28.8°/s. After the nystagmus disappeared, he showed a geotropic nystagmus. The second patient showed a left-beating nystagmus with an initial SPEV of 2.5°/s and a TC of 141 s when his head was rotated to the right in supine position. The nystagmus then gradually declined with a TC of 8.05 s after reaching a maximum SPEV of 16.7°/s. After the nystagmus disappeared, he showed a geotropic nystagmus. The present findings suggested that in both patients, at the period of an increase of SPEV of the positional nystagmus with the shortening of its TC, cupulolithiasis transformed into canalolithiasis.     

上半规管良性阵发性位置性眩晕41例

目的 探讨上半规管良性阵发性位置性眩晕(BPPV)诊断和治疗的最佳方案。方法 回顾性分析41例上半规管BPPV患者的病历资料,并对所有患者的诊断及复位进行评估分析。结果 SRM-Ⅳ模拟Dix-Hallpike试验诱发出典型垂直向下眼震28例(68.3%),其中眼震伴有向地扭转的成分19例,不伴有扭转成分9例;SRM-Ⅳ上半规管BPPV诱发试验诱发出典型垂直向下眼震35例(84.6%),其中眼震伴有向地扭转的成分30例,不伴有扭转成分5例。在所有41例患者中有38例能通过两种诱发试验对受累侧别做出判断,其中因诱发眼震伴有扭转成分而判断侧别30例,单侧诱发诱发出垂直向下眼震且不伴有扭转成分3例,双侧诱发出垂直向下眼震5例,且不伴有扭转成分,但因眩晕及眼震的强度有明显差别而判断出侧别,患者对受累侧别不能判断3例。在能判断出侧别的38例患者中有左侧上半规管受累25例,右侧上半规管受累13例。对41例采用SRM-Ⅳ上半规管BPPV复位法进行治疗,通过一次治疗痊愈28例,有效12例,无效1例。结论 上半规管BPPV 临床上被越来越重视,应用SRM-ⅣBPPV诊疗系统对上半规管BPPV进行诊治效果好,应该在临床得到推广。     

Extraocular muscle contraction as a tool for benign paroxysmal positional vertigo diagnosis

When diagnosing benign paroxysmal positional vertigo, extraocular muscle contraction and the nystagmus it causes, though recognized as an important indicator, is less commonly seen as a principal method of diagnosis. However, through determining the direction of resulting nystagmus during diagnostic tests such as the supine roll test and the Dix-Hallpike test, which semicircular canals are involved in individual cases of benign paroxysmal positional vertigo can be ascertained, in both cases involving only one semicircular canal or cases of multi-canal benign paroxysmal positional vertigo.     

Diagnosis and treatment of anterior canal benign paroxysmal positional vertigo

Abstract

Objective: To investigate the diagnosis and treatment of anterior canal benign paroxysmal positional vertigo (AC-BPPV).

Design: Retrospective analysis of clinical data regarding the diagnosis and treatment of patients with AC-BPPV.

Study sample: Six patients with AC-BPPV.

Results: All patients underwent the Dix–Hallpike test and/or the straight head-hanging test to induce vertigo and down-beating nystagmus with or without torsional components. Down-beating nystagmus in patients 1, 3 and 6 lasted <1?min and was successfully treated with the Yacovino manoeuvre. Down-beating nystagmus in patients 2, 4 and 5 lasted >1?min. The Yacovino manoeuvre was not effective in patient 4, whereas it was effective in patient 2 but with frequently recurring symptoms. Patients 3, 4 and 6 also had other types of typical BPPV. Canal conversion appeared in patients 4 and 5 during the follow-up period.

Conclusion: Typical BPPV, canal conversion, a therapeutic diagnosis after applying the Yacovino manoeuvre, and the follow-up outcome contribute to AC-BPPV diagnosis in patients with dizziness and vertigo presenting with down-beating positional nystagmus. Yacovino manoeuvre was more effective in AC-BPPV patients with down-beating positional nystagmus lasted <1?min than in those in whom it lasted >1?min.     

Cupulolithiasis of the posterior semicircular canal

Background

We sometimes experience patients with persistent torsional/vertical (upbeating) positional nystagmus in the head-hanging position. We have been convinced of the existence of cupulolithiasis of the posterior semicircular canal because such cases reveal persistent torsional/vertical (downbeating) positional nystagmus in the nose-down position.

Purpose

In order to confirm the validity of Ewald's third law, we quantified the difference between positional nystagmus in the head-hanging position and that in the nose-down position.

Methods

The subjects were 10 patients with posterior cupulolithiasis, 9 female and 1 male, with a mean age of 58.9 years. Nystagmus was recorded using an infrared camera and the findings were converted to digital data. Using ImageJ, we performed three-dimensional video-oculography and measured the maximum slow-phase velocity (MSV) of three components.

Results

In the horizontal component, the mean value of MSV in the head-hanging position was 3°/s, and that in the nose-down position was 2.7°/s. There was no significant difference between the two positions. In the vertical component, the mean value of MSV in the head-hanging position was 4.3°/s, and that in the nose-down position was 6°/s. There was no significant difference between the two positions. In the torsional component, the mean value of MSV in the head-hanging position was 4.4°/s, and that in the nose-down position was 1.4°/s. The former was significantly greater than the latter (p < 0.01).

Conclusions

Although we could not confirm the validity of Ewald's third law, the torsional component in the head-hanging position was significantly greater than that in the nose-down position.     

Positional nystagmus showing neutral points

We encountered patients who had their static direction-changing positional nystagmus canceled at about 20-30 degrees yaw head rotation from the supine position. This nystagmus was also canceled when the head was rotated 180 degrees from this position. We call these head positions neutral points. At the neutral points, the cupula of the horizontal semicircular canal of the affected ear is positioned vertical to the gravitational plane and no deflection of the cupula occurs. The positional nystagmus observed (except the neutral points) was thought to occur due to a "heavy cupula" or "light cupula", which may be determined by the specific gravity of its endolymph.     

Prospective study of positional nystagmus in 100 consecutive patients

OBJECTIVES: The purpose of this study was to investigate the various diagnoses of patients who present with positional nystagmus. METHODS: Positional maneuvers were systematically performed in the plane of the posterior canal (PC; Dix-Hallpike maneuver) and the horizontal canal (HC; patients were rolled to either side in a supine position) on 490 consecutive patients essentially referred for vertigo and/or gait unsteadiness. RESULTS: One hundred patients (20%) presented positional nystagmus. This nystagmus had a peripheral origin in 83 patients, including 80 patients with benign paroxysmal positional vertigo (BPPV). In BPPV, the PC was involved in 61 patients, the HC in 18 patients (geotropic horizontal nystagmus in 11 and ageotropic in 7; changing from geotropic to ageotropic or the reverse in 4 patients), and both the PC and HC in 1 patient. There was evidence of central positional nystagmus in 12 patients, including positional downbeat nystagmus during the Dix-Hallpike maneuver in 7 patients with various neurologic disorders, and ageotropic horizontal nystagmus during the HC maneuver in 2 patients with, respectively, cerebellar ischemia and definite migrainous vertigo. The peripheral or central origin of the positional nystagmus could not be ascertained in 5 patients, including 1 patient with probable migrainous vertigo and another with possible anterior canal BPPV. CONCLUSIONS: A rotatory-upbeat nystagmus in the context of PC BPPV, a horizontal nystagmus, whether geotropic or ageotropic, due to HC BPPV, and a positional downbeat nystagmus related to various central disorders are the 3 most common types of positional nystagmus. Geotropic horizontal positional nystagmus and, most certainly, horizontal positional nystagmus changing from geotropic to ageotropic or the reverse point to HC BPPV. In contrast, an ageotropic horizontal positional nystagmus that is not changing (from ageotropic to geotropic) may indicate a central lesion.     

Benign paroxysmal positional vertigo of the horizontal semicircular canal

ObjectiveAssesment of 8 new cases of benign paroxysmal positional vertigo of the horizontal semicircular canal (BPPV-HC), since this variant of benign positional vertigo occurs rarely. An oculographic study of features in the positional response was carried out. Electrooculograpy (EOG) allows an exhaustive study of positional nystagmus.Material and methodsWe have studied retrospectively 8 patients with BPPV-HC and positive head rotation manoeuvre registered by EOG techniques. Possible alterations in other EOG tests in the group of patients were analyzed.ResultsMost of the patients (7/8) expressed bilateral horizontal geotropic changing-direction nystagmus. One patient exhibited apogeotropic horizontal nystagmus. 5/8 cases showed caloric hypofunction.ConclusionsWe have proven that BPPVHC is an uncommon disorder. In most of the cases, provocative manoeuver generates bilateral horizontal geotropic changing-direction nystagmus that probably is due to canalitiasis of the horizontal semicircular canal. The rest, a few cases, exhibit apogeotropic horizontal response that can be secondary to cupulolitiasis or location particles in the anterior portion of the horizontal canal. A caloric test showed abnormal in many and can help to locatize the affected ear.     

Vertical component of the caloric response, including a caloric second phase provoked by positional change: a preliminary report

We measured the horizontal and vertical components of caloric nystagmus in 120 ears of 60 vertiginous patients who had moderate to vigorous caloric first-phase response in both ears, no spontaneous nystagmus, and no severe disorders in the central nervous system. We provoked a caloric first phase in the supine position with 5 ml of water at 20 degrees C for 15 seconds. We provoked a caloric second phase by changing the position of a patient from supine to sitting after the end of the first phase. The horizontal component of the caloric second phase was recorded in 108 of 120 ears (90%). The vertical component was recorded in 57 of 120 ears (48%) during the caloric first phase and in 51 of 120 ears (43%) during the caloric second phase. We suspected that the vertical component of the caloric first phase was mainly due to the inhibition of the anterior semicircular canal.     

Conversion of canalolithiasis to cupulolithiasis in the course of a horizontal benign paroxysmal positional vertigo case

The benign paroxysmal positional vertigo of the horizontal semicircular canal is manifested with either geotropic or apogeotropic horizontal nystagmus. A 61-year-old male patient who experienced repeated episodes of positional vertigo is presented in this study. The vertigo was reported to be more severe while rotating his head to the left and then to the right. The initial examination revealed a geotropic purely horizontal nystagmus at the lateral positions of the head compatible with canalolithiasis of the left horizontal semicircular canal. In this case, the otoconia debris migrates from the vestibule into the horizontal semicircular canal through its nonampullary end, where they float freely (canalolithiasis). Five days later, the geotropic nystagmus transformed to apogeotropic. Thus, it may be assumed that the otoconia debris adhered to the cupula and converted the canalolithiasis to cupulolithiasis of the horizontal semicircular canal on the same side. With rotation of the head to the left while the patient was in the supine position, gravity causes the weighted cupula to deflect ampullofugally, resulting in apogeotropic nystagmus; the opposite was noticed when the head was rotated to the right. The so-called barbecue maneuver was initially effective curing the geotropic form of the condition and consequently the modified Semont maneuver for the apogeotropic form.