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.     

Horizontal canal type BPPV: bilaterally affected case treated with canal plugging and Lempert's maneuver

A 54-year-old woman complained of positional vertigo. During 3 months' observation, the patient showed mostly geotropic or apogeotropic nystagmus due to right canalolithiasis or cupulolithiasis, however, she sometimes showed nystagmus which suggested left horizontal canalolithiasis. We suspected that she suffered from bilateral horizontal canal type benign paroxysmal positional vertigo (BPPV) and performed Lempert's maneuver for both directions, however, they were ineffective. She underwent canal plugging for right horizontal canal. After surgery she showed no positional nystagmus of right horizontal canal origin. However, apogeotropic nystagmus of the left horizontal canal origin was still observed. This nystagmus changed to geotropic nystagmus and finally disappeared following Lempert's maneuver for the left side. Bilateral horizontal canal BPPV is difficult to be resolved, probably because physical treatment for one side would move debris to the cupula in the other canal. Canal plugging combined with Lempert's maneuver to the other side is one treatment option for intractable bilateral horizontal canal BPPV.     

New treatment strategy for cupulolithiasis associated with benign paroxysmal positional vertigo of the lateral canal: the head-tilt hopping exercise

This study was performed to determine whether a novel treatment was effective against cupulolithiasis associated with benign paroxysmal positional vertigo (BPPV) of the lateral semicircular canal, which is characterized by apogeotropic direction-changing nystagmus. We herein describe our head-tilt hopping (HtH) exercise, which is designed to release otoconial debris strongly adhered to the cupula. The subjects were trained to hop while tilting their heads laterally. They completed 3 to 5 exercise sessions per day over a 4-week period. Each session ended with a 20-hop trial. The HtH exercises were performed by 27 patients with intractable lateral canal BPPV who exhibited positional vertigo and persistent nystagmus beating toward the uppermost ear for more than 4 weeks, despite performing therapeutic head shaking in the horizontal plane maneuver. All the patients were subjected to the supine roll test before and immediately after the first trial as well as after 1 and 4 weeks of the program to evaluate the effect of the treatment on their apogeotropic nystagmus. Nystagmus of 9 (33.3 %) patients disappeared immediately after the first training session. After 1 and 4 weeks of the training, the number of patients that had experienced either of these improvements had increased to 15 (55.6 %) and 19 (70.4 %) subjects, respectively. These results suggest that HtH exercises aimed at releasing otoconial debris from the cupula are feasible as a new therapy for cupulolithiasis associated with intractable lateral canal BPPV. However, further studies for comparison with control are required to confirm these preliminary results.     

手法复位治疗良性阵发性位置性眩晕36例

目的 评价体位治疗在良性阵发性位置性眩晕（BPPV）的应用价值。方法 回顾性分析36例原发性或继发性BPPV的临床资料,后半规管BPPV采用改良Epley手法或Semont手法复位,水平半规管采用Barbecue翻滚疗法复位治疗,评价其治疗效果。结果 33例后半规管BPPV患者应用改良Epley手法或Semont手法复位,有效率为93.9%。3例水平半规管BPPV患者采取Barbecue翻滚法复位后症状均明显改善。结论 手法复位治疗良性阵发性位置性眩晕方法简单,疗效可靠,治愈率高。     

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     

Diagnosis and treatment of the short-arm type posterior semicircular canal BPPV

IntroductionThe Epley maneuver is useful for the otoconia to return from the long arm of the posterior semicircular canal into the utricle. To move otoconia out of the posterior semicircular canal short arm and into the utricle, we need different maneuvers.ObjectiveTo diagnose the short-arm type BPPV of the posterior semicircular canal and treat them with bow-and-yaw maneuver.Methods171 cases were diagnosed as BPPV of the posterior semicircular canal based on a positive Dix–Hallpike maneuver. We first attempted to treat patients with the bow-and-yaw maneuver and then performed the Dix–Hallpike maneuver again. If the repeated Dix–Hallpike maneuver gave negative results, we diagnosed the patient with the short-arm type of BPPV of the posterior semicircular canal and considered the patient to have been cured by the bow-and-yaw maneuver; otherwise, probably the long-arm type BPPV of the posterior semicircular canal existed and we treated the patient with the Epley maneuver.ResultsApproximately 40% of the cases were cured by the bow-and-yaw maneuver, giving negative results on repeated Dix–Hallpike maneuvers, and were diagnosed with short-arm lithiasis.ConclusionThe short-arm type posterior semicircular canal BPPV can be diagnosed and treated in a convenient and comfortable manner.     

The Epley manoeuvre for benign paroxysmal positional vertigo – a systematic review

Benign paroxysmal positional vertigo (BPPV) is a syndrome characterized by short‐lived episodes of vertigo in association with rapid changes in head position. Current treatment approaches include rehabilitative exercises and physical manoeuvres including the Epley manouevre. Randomized clinical trials of the Epley manoeuvre were identified. Outcome measures that were considered include: frequency and severity of attacks of vertigo; proportion of patients improved by each intervention; and conversion of a ‘positive’ Dix–Hallpike test to a ‘negative’ Dix–Hallpike test. Patients who received the Epley manoeuvre were more likely to have complete resolution of their symptoms [odds ratio 4.92 (95% C.I. 1.84–13.16)], and more likely to convert from a positive to negative Dix–Hallpike test [odds ratio 5.67 (95% C.I. 2.21–14.56)]. There were no serious adverse effects of treatment. There is some evidence that the Epley manouevre is a safe effective treatment for posterior canal BPPV.     

Benign positional paroxysmal vertigo in the general ear, nose, and throat clinic

Benign positional paroxysmal vertigo is a common disease which may be caused by abnormal movement of utricular debris in the posterior semicircular canal. It is diagnosed by the Dix-Hallpike positional maneuver eliciting vertigo and nystagmus. Treatment generally consists of physical exercises with the Epley or Semont maneuvers. We review 43 consecutive patients diagnosed as BPPV in the last year and treated with physical therapy (Epley maneuvers). Results were very good, with a cure rate of 88.37% (53.5% after a single maneuver). Physical therapy is an effective treatment for BPPV.     

“Sitting-up vertigo as an expression of posterior semicircular canal heavy cupula and posterior semicircular canal short arm canalolithiasis”

BackgroundVestibular symptoms on sitting-up are frequent on patients seen by vestibular specialists. Recently, a benign paroxysmal positional vertigo (BPPV) variant which elicits vestibular symptoms with oculomotor evidence of posterior semicircular canal (P-SCC) cupula stimulation on sitting-up was described and named sitting-up vertigo BPPV. A periampullar restricted P-SCC canalolithiasis was proposed as a causal mechanism.ObjectiveTo describe new mechanisms of action for the sitting-up vertigo BPPV variant.MethodsEighteen patients with sitting-up vertigo BPPV were examined with a pre-established set of positional maneuvers and follow-up until they resolved their symptoms and clinical findings.ResultsAll patients showed up-beating torsional nystagmus (UBTN) and vestibular symptoms on coming up from either Dix-Hallpike (DHM) or straight head-hanging maneuver. Sixteen out of 18 patients presented a sustained UBTN with an ipsitorsional component to the tested side on half-Hallpike maneuver (HH). A slower persistent contratorsional down-beating nystagmus was found in eleven out 18 patients tested on nose down position (ND).ConclusionsPersistent direction changing positional nystagmus on HH and ND positions indicative of P-SCC heavy cupula was found in 11 patients. A sustained UBTN on HH with the absence of findings on ND, which is suggestive of the presence of P-SCC short arm canalolithiasis, was found on 5 patients. All patients were treated with canalith repositioning maneuvers without success, but they resolved their findings by means of Brandt-Daroff exercises. We propose P-SCC heavy cupula and P-SCC short arm canalolithiasis as two new putative mechanisms for the sitting-up vertigo BPPV variant.     

外半规管良性阵发性位置性眩晕的诊疗

良性阵发性位置性眩晕(benign paroxysmal positional vertigo,BPPV)是最常见的周围性眩晕,主要表现为随头位变化出现的短暂性眩晕发作,该病分为后半规管型、外半规管型、上半规管型及多半规管.其中后半规管BPPV最常见,其次为外半规管BPPVo外半规管BPPV根据发病机制、原理、眼震方向等有多种分类方法.近年来外半规管BPPV的手法复位逐渐被熟悉,但一些患者复位后效果不佳,如外半规管嵴帽结石症,部分患者行常规手法复位后发作性眩晕仍然存在.我们将这部分手法复位后眩晕症状改善不明显的类型归结为难治型外半规管嵴帽结石症.本文主要围绕外半规管BPPV的概念及分类、流行病学、病因、发病机制、诊断及复位方法,尤其对于难治型外半规管嵴帽结石症的复位方法做一综述.     

Combined horizontal and posterior canal benign paroxysmal positional vertigo in three patients with head trauma

We report 3 patients who complained of positional vertigo shortly after head trauma. Positional maneuvers 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 with the head raised 30 degrees) revealed a complex positional nystagmus that could only be interpreted as the result of combined PC and HC benign paroxysmal positional vertigo (BPPV). Two patients had a right PC BPPV and an ageotropic HC BPPV, and 1 patient had a bilateral PC BPPV and a left geotropic HC BPPV. All 3 patients were rapidly free of vertigo after the PC BPPV was cured by the Epley maneuver and the geotropic HC BPPV was cured by the Vannucchi method. The ageotropic HC BPPV resolved spontaneously. Neuroimaging (brain computed tomography and/or magnetic resonance imaging scans) findings were normal in all 3 patients. From a physiopathological viewpoint, it is easy to conceive that head trauma could throw otoconial debris into different canals of each labyrinth and be responsible for these combined forms of BPPV. Consequently, in trauma patients with vertigo, it is mandatory to perform the Dix-Hallpike maneuver, as well as supine lateral head turns, in order to diagnose PC BPPV, HC BPPV, or the association of both. Early diagnosis and treatment of BPPV may help to reduce the postconcussion syndrome.     

Rare complications following stapes operation and their surgical treatment

After stapedectomy otoliths were displaced from the endolymphatic space to the cupula of the posterior semicircular canal and caused a paroxysmal benign positional nystagmus which lasted 18 months. The positional nystagmus demonstrated a rotatory component during the Hallpike manoeuvre. The paroxysmal benign nystagmus disappeared after transtympanic nerve neurectomy of the inferior branch of the vestibular nerve (Gacek 1974). This procedure is only recommended for vertigo lasting longer than 1 year. The current findings support the theory that cupulolithiasis is the cause of paroxysmal benign positional nystagmus which can occur after stapedectomy. The rotatory nystagmus is generated in the posterior semicircular canal.     

Model experiment of benign paroxysmal positional vertigo mechanism using the whole membranous labyrinth

Whole membranous labyrinths of bullfrogs were used in order to replicate the human vestibule. The posterior semicircular canals (PSCs) were exposed, leaving the remaining membranous labyrinth encapsulated in the otic capsule. Vibration was applied to the surface of the bony capsule using a conventional surgical drill in order to dislodge the otoconia from the utricle. The position of the preparation was controlled so that the dislodged otoconia were attached to the cupular surface. This was regarded as a cupulolithiasis model. The action potentials changed instantaneously according to the gravitational force on the cupula. When the otoconia were dislodged and held within the PSC lumen, the position of the whole preparation was changed so that the otoconia moved back and forth within the canal lumen. This is a model of canalolithiasis. The action potentials changed in combination with the otoconial movement after a latent period. Both cupulolithiasis and canalolithasis are potentially valid mechanisms of benign paroxysmal positional vertigo (BPPV). However, canalolithiasis is the most likely mechanism of BPPV, which is usually characterized by nystagmus of short duration and long latency. A vibratory stimulus was able to detach the otoconia from the utricle, suggesting that mechanical insult could be a possible etiology of BPPV.     

Experimental study of speed-dependent positional nystagmus in benign paroxysmal positional vertigo

OBJECTIVE: One of the clinical characteristics of benign paroxysmal positional vertigo (BPPV) is that the more quickly the head position changes, the more severe the vertigo. This suggests that the velocity of the head change is critical in determining the occurrence and severity of vertigo. The aim of this study was to examine factors determining the symptoms of BPPV using models of canalolithiasis and cupulolithiasis. MATERIAL AND METHODS: Canalolithiasis and cupulolithiasis models were prepared using the bullfrog posterior semicircular canal (PSC). The ampullary nerve discharges were compared between quick and slow positional changes to examine factors determining the symptoms of BPPV. RESULTS: In the canalolithiasis model, the acceleration of the otoconia was greater for the quick positional change. This resulted in a greater discharge with a longer duration. With the slow positional change, the discharges were smaller and shorter. In the cupulolithiasis model, the discharges were sustained and their magnitude did not differ between the quick and slow positional changes. The canalolithiasis model influenced the magnitude of discharge of the PSC depending on the speed of the positional change. CONCLUSION: Canalolithiasis is the more likely mechanism of BPPV, which is characterized by various degrees of vertigo upon kinetic positional change.     

A new variant of posterior canal-benign paroxysmal positional vertigo-canalolithiasis

ObjectiveThe characteristics of typical posterior canal-benign paroxysmal positional vertigo-canalolithiasis (P-BPPV-Can) are well known. We found 10 patients with a new variant of P-BPPV-Can: Reverse (Rev)-P-BPPV-Can. The characteristics and pathophysiology of Rev-P-BPPV-Can are discussed.MethodsFor 4 years and 9 months, 10 patients with Rev-P-BPPV-Can (9 women and 1 man; mean age: 73 years) visited our clinic. Within the same period, 268 patients with unilateral typical P-BPPV-Can were treated. During the Dix–Hallpike and Epley maneuvers, nystagmus was recorded using an infrared charge-coupled device camera mounted on a pair of spectacles.ResultsThe patients exhibited entirely opposite direction of nystagmus from typical P-BPPV-Can in both the Dix–Hallpike head position and upright sitting position. The patients had typical characteristics of nystagmus due to canalolithiasis, such as latency, duration of <1 min, linear-torsional nystagmus, and fatigability. Rev-P-BPPV-Can appeared after the Epley maneuver for typical P-BPPV-Can; in other patients, Rev-P-BPPV-Can changed to typical P-BPPV-Can. The affected sides of Rev-P-BPPV-Can were decided by those of typical P-BPPV-Can.ConclusionCanalolithiasis in the non-ampullary distal portion of the posterior semicircular canal may be a potential pathophysiology of Rev-P-BPPV-Can. The Epley maneuver has little effect for treating Rev-P-BPPV-Can, but spontaneous transition to typical P-BPPV-Can or spontaneous recovery is expected.     

Inkurabler und atypischer benigner paroxysmaler Lagerungsschwindel

Benign paroxysmal positional vertigo (BPPV) is the most frequent vestibular disorder and a most common cause of dizziness and vertigo. The modern canalolithiasis theory postulates the existence of free-floating dense otolithic particles in the endolymph of the posterior semicircular canal. The symptoms were exactly described by Dix and Hallpike; BPPV is normally a self-limited disease with spontaneous recovery. There is however a small number of patients who do not respond to any treatment or who present with otolithic vertigo which does not fit all Dix-Hallpike criteria (atypical BPPV). While BPPV in its typical appearance cannot be diagnosed with radiologic imaging, the authors succeeded in identifying structural changes in the vestibular organs of patients suffering from intractable or atypical BPPV using three-dimensional magnetic resonance imaging.     

Intractable and atypical benign paroxysmal vertigo. Pathological results of high-resolution three-dimensional MR-tomography of the vestibular organ

Benign paroxysmal positional vertigo (BPPV) is the most frequent vestibular disorder and a most common cause of dizziness and vertigo. The modern canalolithiasis theory postulates the existence of free-floating dense otolithic particles in the endolymph of the posterior semicircular canal. The symptoms were exactly described by Dix and Hallpike; BPPV is normally a self-limited disease with spontaneous recovery. There is however a small number of patients who do not respond to any treatment or who present with otolithic vertigo which does not fit all Dix-Hallpike criteria (atypical BPPV). While BPPV in its typical appearance cannot be diagnosed with radiologic imaging, the authors succeeded in identifying structural changes in the vestibular organs of patients suffering from intractable or atypical BPPV using three-dimensional magnetic resonance imaging.     

Postural restrictions in labyrintholithiasis

Benign paroxysmal positional vertigo (BPPV) is the most frequent labyrinthopathy in humans. Treatment consists mainly of liberatory maneuvers aiming to remove otolithic debris and subsequent postural restrictions in order to prevent debris from returning into the canal. The reappearance of symptoms after an effective liberatory maneuver was studied in a group subjected to restrictions and in a second group free from restrictions. The effects of these restrictions were evaluated. No statistically significant difference was found between the groups. Accordingly, restrictions seem to have no effect upon symptom recurrence. The slight supremacy of the Semont maneuver and the prevalence of subsequent relapse compared with the Epley maneuver suggests that these maneuvers could operate on different disorders (cupulolithiasis versus canalolithiasis). Finally, late recognition of relapse in patients who undergo restrictions might even make the liberatory maneuver less effective.     

3D analysis of benign positional nystagmus due to cupulolithiasis in posterior semicircular canal

Conclusions: The characteristic of both the vertical-torsional positional nystagmus with long time constant and its disappearance at the neutral head position could diagnose cupulolithiasis in posterior semicircular canal (PSCC) in the eight patients with the PSCC type of benign paroxysmal positional vertigo (P-BPPV). Objective: The aim of the study was to diagnose cupulolithiasis in patients with P-BPPV. Patients and methods: We used three-dimensional rotation axis analysis of nystagmus of the vertical-torsional positional nystagmus in 111 patients with P-BPPV and evaluated its time constant. We then examined whether the vertical-torsional positional nystagmus with long time constant disappeared at the neutral head position where the axis of the heavy cupula of the affected PSCC is aligned with gravity. Results: The first parameter showed a wide variation that could be divided into two groups: one lasting more than 40 s in 8 patients and another below 20 s in 103 patients. Since the time constant of the positional nystagmus induced by cupulolithiasis was much longer than that induced by canalolithiasis, this finding suggests that cupulolithiasis in the PSCC induced the vertical-torsional positional nystagmus with a long time constant in the group of eight patients. The vertical-torsional positional nystagmus disappeared in these patients at the neutral head position, where the axis of the cupula of affected PSCC aligned with gravity.     

Experimental Study of Speed-dependent Positional Nystagmus in Benign Paroxysmal Positional Vertigo

Objective—One of the clinical characteristics of benign paroxysmal positional vertigo (BPPV) is that the more quickly the head position changes, the more severe the vertigo. This suggests that the velocity of the head change is critical in determining the occurrence and severity of vertigo. The aim of this study was to examine factors determining the symptoms of BPPV using models of canalolithiasis and cupulolithiasis. Material and Methods—Canalolithiasis and cupulolithiasis models were prepared using the bullfrog posterior semicircular canal (PSC). The ampullary nerve discharges were compared between quick and slow positional changes to examine factors determining the symptoms of BPPV. Results—In the canalolithiasis model, the acceleration of the otoconia was greater for the quick positional change. This resulted in a greater discharge with a longer duration. With the slow positional change, the discharges were smaller and shorter. In the cupulolithiasis model, the discharges were sustained and their magnitude did not differ between the quick and slow positional changes. The canalolithiasis model influenced the magnitude of discharge of the PSC depending on the speed of the positional change. Conclusions—Canalolithiasis is the more likely mechanism of BPPV, which is characterized by various degrees of vertigo upon kinetic positional change.