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.     

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.     

Epley's manoeuvre: treatment of choice for benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is one of the commonest causes of peripheral vestibular disorders. In this prospective study 21 patients with BPPV were treated by Epley's manoeuvre. All patients had an immediate improvement in their symptoms. Recurrence was noted in three patients who required further treatment sessions with resultant improvement in all. However, one patient who originally had suffered from Ménière's disease involving the same ear for more than 14 years developed another recurrence which was treated successfully by further application of Epley's manoeuvre. This study supports the usefulness of Epley's manoeuvre for the treatment of BPPV.     

Benign paroxysmal positional vertigo of the horizontal and superior semicircular canals

The incidence of benign paroxysmal positional vertigo (BPPV) of the horizontal and superior semicircular canals is much less than that of BPPV due to affection of the posterior semicircular canal. Their diagnosis is however much more difficult and still prone to controversies. The provocative manoeuvre of the BPPV of the horizontal canal (BPPV-HSC) is the manoeuvre of rotation of the head in dorsal position. A horizontal positional nystagmus is obtained. There are two forms of BPPV-HSC: the geotropic form and the ageotropic form. In the geotropic form, the liberatory manoeuvre is a "barbecue" rotation of 180 with 360 degrees towards the healthy side. In the ageotropic form, there is no universal liberatory manoeuvre. Moreover as some cases of neurological aetiology have been recognized, it is not appropriate to apply ineffective manoeuvres. The BPPV of the superior canal (BPV-SSC) is very rare. The provocative manoeuvre is the Dix and Hallpike's manoeuvre. It causes positional torsional and vertical nystagmus with an opposite direction to that obtained for a BPPV of the contra-lateral posterior canal. The liberatory manoeuvre is a Semont manoeuvre, which is identical to that we would make for a contra-lateral BPPV of the posterior canal.     

同时性后半规管与水平半规管性良性位置性眩晕

目的：探讨同时性后半规管与水平半规管性良性位置性眩晕（混合性良性位置性眩晕）的诊治方法。方法：联合应用Epley手法和Barbecue翻滚法对4例患者进行治疗，两次治疗间隔1d。结果：4例患者眩晕症状完全消失，随访至今无复发。结论：混合性良性位置性眩晕兼有后半规管与水平半规管性良性位置性眩晕的临床表现，联合采用Epley手法和Barbecue翻滚法治疗该病是可行的。     

The test and treatment methods of benign paroxysmal positional vertigo and an addition to the management of vertigo due to the superior vestibular canal (BPPV‐SC)

A review of the tests and treatment manoeuvres for benign paroxysmal positional vertigo of the posterior, horizontal and superior vestibular canals is presented. Additionally, a new way to test and treat positional vertigo of the superior vestibular canal is presented. In a prospective study, 57 out of 305 patients' visits are reported. They had residual symptoms and dizziness after the test and the treatment of benign paroxysmal positional vertigo of the horizontal canal (BPPV‐HC) and posterior canal (PC). They were tested with a new test and treated with a new manoeuvre for superior canal benign paroxysmal positional vertigo (BPPV‐SC). Results for vertigo in 53 patients were good; motion sickness and acrophobia disappeared. Reactive neck tension to BPPV was relieved. Older people were numerous among patients and their quality of life (QOL) improved.     

The test and treatment methods of benign paroxysmal positional vertigo and an addition to the management of vertigo due to the superior vestibular canal (BPPV-SC)

A review of the tests and treatment manoeuvres for benign paroxysmal positional vertigo of the posterior, horizontal and superior vestibular canals is presented. Additionally, a new way to test and treat positional vertigo of the superior vestibular canal is presented. In a prospective study, 57 out of 305 patients' visits are reported. They had residual symptoms and dizziness after the test and the treatment of benign paroxysmal positional vertigo of the horizontal canal (BPPV-HC) and posterior canal (PC). They were tested with a new test and treated with a new manoeuvre for superior canal benign paroxysmal positional vertigo (BPPV-SC). Results for vertigo in 53 patients were good; motion sickness and acrophobia disappeared. Reactive neck tension to BPPV was relieved. Older people were numerous among patients and their quality of life (QOL) improved.     

Epley's canalith-repositioning manoeuvre for benign paroxysmal positional vertigo

The efficacy of the Epley's canalith-repositioning manoeuvre in the treatment of BPPV was assessed in this prospective study of 62 patients. Patients were selected based on symptoms of positional vertigo and positive Dix-Hallpike's positional test. Patients were divided into two groups; first group comprising 34 patients underwent Epley's manoeuvre alone where as the other group comprising 28 patients underwent Epley's manoeuvre along with mastoid oscillator. At the end of 1 month patients were assessed subjectively by visual analogue scale (VAS) and objectively by Dix-Hallpike's positional test. On VAS, 85.7% patients had complete resolution of symptoms of BPPV in both the groups. Objectively 88.2% did not have positional nysfagmus after 1 month in first group whereas in the second group 86% had complete response at the end of 1 month of therapy. Follow up of 6 months could be done in 38 patients, out of which 7 (18.4%) had recurrence of their symptom of vertigo and positive Dix-Hallpike's positional test, whereas one patient continued to have no relief by Epley's manoeuvre. There was no difference in subjective and objective parameters even when CRP was performed using mastoid vibrator.     

突发性聋伴发良性阵发性位置性眩晕的临床特点及疗效观察

目的　探讨突发性聋伴发良性阵发性位置性眩晕（benign paroxysmal positional vertigo,BPPV）的临床特点,观察其疗效。方法　观察2012年10月～2014年6月耳 鼻咽喉科收治的36例突发性聋伴发BPPV发病情况,并与同期原发性BPPV患者40例及突发性聋不伴眩晕患者40例进行疗效比较。结果　伴发BPPV的36例突发性聋患者,受累半规管均与突发性聋发病侧一致,其中水平半规管BPPV 6例,占16.7%（6/36）;后半规管BPPV 27例,占75.0%（27/36）;混合管BPPV 3例,占8.3%（3/36）。36例患者出现BPPV的时间均在突发性聋发病后数小时至数天（＜10天）发生。突发性聋伴发BPPV组1次治愈率明显低于原发性BPPV组,但两种治疗方法的总治愈率均为100%。不伴眩晕突发性聋组的痊愈率、显效率及有效率均高于伴发BPPV组。结论　伴发于突发性聋的BPPV以后半规管多见,与原发性BPPV经耳石复位治疗后均可取得较好疗效。而不伴眩晕的突发性聋其疗效优于伴发BPPV的突发性聋。     

Recurrence of symptoms following treatment of posterior semicircular canal benign positional paroxysmal vertigo with a particle repositioning manoeuvre

A consecutive series of 51 patients (34 females and 17 males) with posterior semicircular canal benign positional paroxysmal vertigo (BPPV) were treated with the modified Epley particle positioning manoeuvre (PRM). Follow-up data were available on all 51 patients. After one manoeuvre, 42 patients had a negative Dix-Hallpike test, and after a second manoeuvre, 8 of the remaining 9 patients had a negative Dix-Hallpike test (testing was conducted 1 to 2 weeks after the PRM was performed). Therefore, the overall short-term success rate after two manoeuvres was 50 of 51 patients (98%), which is similar to other series. A follow-up questionnaire to determine the incidence of recurrence of symptoms was administered after a minimum period of 30 weeks. Twenty-three patients reported a recurrence (or, in the case of the one treatment failure, persistence) of their symptoms (45%). Therefore, although virtually all patients can be treated successfully with the PRM, almost half of these patients can be expected to experience a further recurrence of symptoms. This long-term recurrence rate is higher than has previously been reported and is a significant factor clinicians must be aware of in their treatment of this condition. In particular, this finding emphasizes the need for patient counselling with regard to the likelihood of recurrence and access to follow-up treatment if recurrence occurs.     

Paroxysmal positional vertigo syndrome.

INTRODUCTION: This study was initiated to investigate the differential diagnosis of patients with benign paroxysmal positional vertigo (BPPV) of different canals' origin. METHODS: The eye movements of 292 patients were evaluated with the use of Frenzel glasses and infrared video cameras after positional tests. Epley's canal repositioning procedure (CRP) was conducted, with appropriate modifications for individual cases, on every patient. RESULTS: Two different types of positional nystagmus were observed corresponding to the presence of otoliths in the lumen of each of the semicircular canals and on the cupola of the horizontal semicircular canal. The posterior canal was involved in 250 patients unilaterally and 23 patients bilaterally. The anterior canal variety was observed in four patients. In the horizontal canal, nine were of the cupulolithiasis and six of the canalithiasis variety. In seven patients. the affected canal converted to a different location. The canal repositioning procedure eliminated vertigo and abnormal eye movements in 88% of the unilateral posterior canal variety. The success rate of the procedure in the other varieties was 50%. CONCLUSION: Positional vertigo can have characteristics corresponding to the presence of otolith particles in each of the semicircular canals. The treatment requires different strategies to move the otoliths, depending on their location in the vestibule.     

Head accelerations during particle repositioning manoeuvres

Benign paroxysmal positional vertigo (BPPV) due to canalithiasis can be treated with particle repositioning manoeuvres, which aim to evacuate trapped particles from the semicircular canals (SCC). The movement of particles within the SCC is affected by gravity as well as by the accelerations of the head during the manoeuvres. Moreover, as experienced by the particles, gravity is indistinguishable from an upward acceleration of the SCC in free space. We used a set of three orthogonal linear accelerometers to measure the net three-dimensional linear acceleration vector acting on the head during the Hallpike manoeuvre and Epley and Semont particle repositioning manoeuvres (which are used to treat posterior canal BPPV). The projection of the net acceleration vector onto the SCC planes showed that both the Epley and Semont manoeuvres approximated to stepwise, 360 degrees , backward rotations in the plane of the targeted posterior canal. Angular velocity measurements however showed that the rotational component during the central stages of these two manoeuvres is opposite in direction. A simple model of head rotations during particle repositioning manoeuvres was created which showed good agreement to the linear acceleration measurements. Analysis of modelled and measured data identified that speed of movement during the Semont manoeuvre should be critical to its clinical success.     

Surgical and physical therapy treatment of benign paroxysmal positional vertigo

Two treatments for the benign paroxysmal positional vertigo are presented and evaluated in this article. The first type of treatment is the surgical section of the posterior ampullary nerve according to Gacek and the second is physiotherapeutic by the manoeuvre of Semont. The section of the posterior ampullary nerve has been realised between 1980 and 1986 on 5 patients suffering from persistent and disabling positional vertigo. All 5 patients were relieved from their vertigo immediately after the operation. One patient developed a post-operative hearing loss. The physiotherapeutic manoeuvre of Semont, which has been developed in order to liberate otolithic deposits from the cupula of the posterior semi-circular canal is applied in our clinic since 1985 as treatment of the benign paroxysmal positional vertigo. The efficiency of the manoeuvre was tested at first in a retrospective study on 50 patients. A single manoeuvre cured 20 of these patients and 15 others were cured after a second manoeuvre. Then, a controlled and prospective study was performed: the clinical course of 40 patients without treatment was compared with 37 patients treated with Semont's manoeuvre. In the group of patients without treatment, only 17 were spontaneously cured from their positional vertigo after 18 days of evolution. In the group treated by Semont's manoeuvre 19 patients were completely healed from vertigo and 16 others were greatly improved. On the basis of these favourable results the authors recommend to treat all cases of paroxysmal positional vertigo at first with Semont's manoeuvre. The section of the posterior ampullary nerve should be restricted to the rare cases with persistent and disabling vertigo.(ABSTRACT TRUNCATED AT 250 WORDS)     

Efficacy of the Semont maneuver in benign paroxysmal positional vertigo

OBJECTIVES: To assess the efficacy of the Semont maneuver in the treatment of benign paroxysmal positional vertigo (BPPV) of the posterior semicircular canal and to evaluate the possible effect of various factors on the efficacy of this maneuver. DESIGN AND SETTING: Retrospective study in an outpatient clinic. PATIENTS: Two hundred seventy-eight patients presenting with symptomatic, unilateral BPPV of the posterior semicircular canal, exclusively treated with the Semont maneuver. INTERVENTIONS: During the first consultation, each patient was treated with a Semont maneuver. When BPPV persisted, this maneuver was repeated during follow-up visits, performed at weekly intervals. MAIN OUTCOME MEASURES: Patients were considered cured when vertigo disappeared within 30 days (allowing up to 4 maneuvers). RESULTS: More than 90% of patients were cured after a maximum of 4 maneuvers, and 83.5% were cured after only 2 maneuvers. The efficacy of the maneuver decreased each time it was repeated (from 62.6% at the first maneuver to 18.2% at the fourth). The duration of symptoms before initial consultation and the etiology of BPPV had a significant effect on the maneuver's efficacy (P<.001 and P =.002, respectively), whereas age (P =.12), sex (P =.06), and affected side (P =.20) had no effect. CONCLUSIONS: The Semont maneuver demonstrated a 90.3% cure rate after a maximum of 4 sessions. Patients consulting late (>6 months after the beginning of symptoms) or having traumatic BPPV had lower recovery rates than patients without these factors (74.7% vs 96.5%).     

Particle repositioning maneuver for benign paroxysmal positional vertigo

The recent demonstration of free-floating particles in the endolymph of the posterior semicircular canal in patients with benign paroxysmal positional vertigo (BPPV)¹ has renewed interest in the physiology and treatment of this entity. The particle repositioning maneuver (PRM) relocates the free-floating particles from the posterior semicircular canal back into the utricle, relieving the patient of bothersome, often long-standing vertigo. This report represents a prospective study of 27 consecutive patients seen with a diagnosis of BPPV. Eighty-four percent of the patients treated with the particle repositioning maneuver who had no other associated pathology were cured or significantly improved with this new technique. Two patients who failed conservative management went on to surgical intervention with the posterior semicircular canal occlusion. The authors find the particle repositioning maneuver effective for many patients with benign positional vertigo and recommend it as the first-line treatment modality for BPPV.     

165例良性阵发性位置性眩晕患者管石复位治疗疗效观察

目的评估BPPV患者管石复位治疗短期和长期疗效。方法回顾分析了后半规管和上半规管BPPV患者165例，男53例、女112例，年龄范围18岁至84岁（平均53岁），分为2组，手法复位治疗（治疗组）125例，非手法复位（对照组）40例。结果治疗组中，后半规管BPPV患者81例，上半规管BPPV患者31例，双侧后半规管BPPV13例。65岁以上老年BPPV患者41例。治疗结果分析．治疗组首次治愈83人（66．4％），其中后半规管BPPV60人（74．1％），上半规管BPPV14人（45．2％），双侧后半规管BPPV9人（69．2％），老年BPPV32人（78．0％）。对照组16人（40％）在一周后症状消失。在4个月至41个月的随访中，治疗组和对照组治愈率分别为92％和82．5％。有30人（24％）在随访中复发。有2例病史超过40个月的患者，手法复位治疗无效而进行后半规管阻塞术。结论手法复位治疗BPPV患者是一种非常有效的方法，它能有效的缩短病程，减轻患者痛苦，其方法简单、易行且费用低，可以在临床广泛使用。     

Treatment of benign positional vertigo using the semont maneuver: efficacy in patients presenting without nystagmus

OBJECTIVE: To evaluate and compare the efficacy of the Semont liberatory maneuver on "objective" benign paroxysmal positional vertigo (BPPV) defined as vertigo with geotropic nystagmus in Dix-Hallpike positioning versus "subjective" BPPV defined as vertigo without nystagmus in Dix-Hallpike positioning. STUDY DESIGN: Retrospective chart review. METHODS: One hundred sixty-two patients with positional vertigo during Dix- Hallpike positioning were identified. Patients were evaluated for the presence or absence of nystagmus. All patients underwent the Semont liberatory maneuver. The patient's condition at follow-up was documented at 3 weeks as complete, partial, or failure. Repeated procedures were performed if necessary. RESULTS: There were 127 cases of objective BPPV and 35 cases of subjective BPPV. Overall, 90% of all patients tested had significant improvement of their vertigo after 1.49 maneuvers on average. Improvement was seen in 91% of patients with objective BPPV after 1.59 maneuvers on average, compared with 86% in subjective BPPV after 1.13 maneuvers on average (chi2 test, not significant [P = .5]). Patients with a history of traumatic origin or cause had an overall success rate of 81% compared with 92% for nontraumatic causes or origins (chi2 test, not significant [P = .1]). Recurrences were seen in 29% of patients after a successful initial maneuver; however, 96% of these patients responded to further maneuvers. Four patients with persistent symptoms after conservative management underwent posterior semicircular canal occlusion with resolution of symptoms. CONCLUSION: The Semont liberatory maneuver provides relief of vertigo in patients with positional vertigo, even in patients without objective nystagmus.     

Assessment of sensory organization testing in benign paroxysmal positional vertigo patients before and after repositioning manoeuvre

Introduction and objectiveBenign paroxysmal positioning vertigo is considered the most common disorder of the peripheral vestibular system. After successful physical manoeuvres for BPPV, a number of patients complain of non-positional sustained imbalance of variable duration called residual dizziness lasting for several days. The objective of this study was to compare the posturographic changes before and one week after successful repositioning manoeuvres in patients with idiopathic BPPV.Materials and methodsThis study was a case–control study, where the first group was composed of 20 patients with confirmed BPPV diagnosis regardless of the affected canal or pathology. Twenty age and gender matched normal subjects constituted the control group. The sensory organization test was performed before and one week after a repositioning manoeuvre in BPPV patients.ResultsAll 20 BPPV patients, except 6 who had no significant improvement of symptoms even after disappearance of classic vertigo and nystagmus, had substantial improvement in sensory scores after CRPs in the antero-posterior visual and vestibular scores and the medio-lateral visual and global scores. All antero-posterior and medio-lateral scores before and after CRPs, except for the AP preferential score, were considerably poorer in BPPV patients than healthy subjects. The 6 patients, who showed no improvement after CRPs, presented with a history of non-specific symptoms i.e., light-headedness or sense of floating.ConclusionsSensory organization test might have a role in the assessment of residual dizziness in patients with BPPV after CRPs.     

Horizontal canal paroxysmal positional vertigo (HCPPV) vs classical BPPV (new concepts about mechanism and domiciliary repositioning of particles)

Some new modificutiont of existing diagnostic and therapeutic manoeuvres (repositioning of particles) have been proposed, basing an the applications of the principles of hydrodynamics, inertial and gravitational forces in the semicircular canals. The above has been tried successfully on patients with benign paroxysmal positional vertigo (BPPV) and horizontal eanal paroxysmal positional vertigo (HCPPV) which can be executed by the patients themselves at home without the kelp of a therapist. Benign paroxysmal positional vertigo (BPPV) is a well-established entity whereas Horizontal Canal Paroxysmal Positional Vertigo (HCPPV) is a recently proposed one. In positional vertigo any canal may be involved. It is quite possible that in the past this diagnosis (HCPPV) was missed in many of the cases of positional vertigo. Kapfschuttel nystagmus (head-shaking nystanmas) is induced by side to side (to and fro) movements of the head around a vertical axis in the plane of the horizontal semicircular canal which is thought to be sensitise the labyrinth, Any manoeuvres that in induce nystagmus with or without vertino is hound to he a manifestation of an organic lesion and not a non-organic one. In a number of instances the postionul test Jor BPPV may yield negative results; but doing this test after kopfschuttel test a dormant positional nystagmus may appear on the surface i.e. uncovered in a number of cases which may have remained undetected if Kopfschutlel manoeuvre were not done. This implies- that by Kopfsi huttel test both the horizontal and vertical canals are sensitised. Moreover, Kopfschuttel nystaagmus is likely to be a manifestation of the horizontal canal stimulation, at leastin some cases, since the movements are executed in the plane of the horizontal canal (vide infra) when displaced otoconia impinges on the cupula /. crista bringing about its stimulation leading to vertigo and or nystagmus.     

咳嗽对良性阵发性位置性眩晕手法复位疗效的影响

目的：分析患良性阵发性位置性眩晕（BPPV）的慢性咳嗽患者经手法复位治疗后的疗效,为BPPV的综合治疗及病因探索提供帮助。方法：分析2009—10—2012—12期间400例BPPV患者的治疗效果,包括观察患者的症状和行体位试验检查。结果：后半规管BPPV的一次治疗成功率为93．4％,水平半规管BPPV治疗成功率为83．0％。在400例BPPV患者中随访到372例,一次治疗成功的复诊患者中,有35例复位治疗好转后又出现阵发性眩晕发作,再次行手法复位仍取得良好效果。追问病史,有29例存在不同程度的咳嗽。控制咳嗽后再行手法复位治疗,眩晕症状消失,随访半年未再发作。结论：BPPV的发生机制可能与咳嗽所致的头部震动有关。