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.     

Repositioning maneuver for the treatment of the apogeotropic variant of horizontal canal benign paroxysmal positional vertigo.

OBJECTIVE: The purpose of this study was to determine the effectiveness of a new physical maneuver in the treatment of the apogeotropic variant of horizontal canal benign paroxysmal positional vertigo. STUDY DESIGN: Case review. SETTING: Outpatient clinic. PATIENTS: The diagnosis of apogeotropic horizontal canal benign paroxysmal positional vertigo was based on the history of recurrent sudden crisis of vertigo associated with bursts of horizontal apogeotropic paroxysmal nystagmus provoked by turning the head from the supine to either lateral position. The patients were three men and five women ranging in age from 31 to 73 years (average, 49.2 yr). INTERVENTIONS: All patients were treated with a repositioning maneuver based on the hypothesis that the syndrome is caused by the presence of free-floating dense particles inside the endolymph of the anterior arm of the horizontal canal. The maneuver favors their shifting into the posterior arm of the canal. Patients were reexamined immediately after the treatment and underwent Gufoni's liberatory maneuver for the geotropic variant of horizontal canal benign paroxysmal positional vertigo. MAIN OUTCOME MEASURE: The treatment outcome was considered as responsive when, after one repositioning maneuver, nystagmus shifted from apogeotropic to geotropic. RESULTS: The repositioning maneuver resulted in a transformation from the apogeotropic variant into a geotropic variant of horizontal canal benign paroxysmal positional vertigo in all patients. CONCLUSION: This maneuver represents a simple and effective approach to the treatment of the apogeotropic variant of horizontal canal benign paroxysmal positional vertigo. It favors the shifting of the canaliths from the anterior into the posterior arm of the horizontal canal from where they can migrate into the utricle with Gufoni's maneuver.     

离地性眼震水平半规管BPPV诊治策略

目的 探讨离地性眼震水平半规管良性阵发性位置性眩晕(HC-BPPV)的诊治策略.方法 回顾性分析2017年7月～2019年6月确诊的48例离地性眼震HC-BPPV患者的临床资料,均采用滚转试验(roll test)、低头仰头试验(bow and lean test)等方法判断侧别,通过Gufoni法、Barbecue法...     

Value of lying-down nystagmus in the lateralization of horizontal semicircular canal benign paroxysmal positional vertigo.

BACKGROUND: Horizontal canal benign paroxysmal positional vertigo is characterized by horizontal direction-changing nystagmus induced by lateral head turning in supine position. According to Ewald's second law, the direction of head turning that creates a stronger response represents the affected side in geotropic nystagmus and the healthy side in apogeotropic nystagmus. However, it may not always be possible to lateralize the involved ear only by comparing the intensity of the nystagmus. We studied the values of nystagmus induced by position change from sitting to supine in the lateralization of horizontal canal benign paroxysmal positional vertigo. METHODS: A retrospective study of 54 patients who had been diagnosed as having horizontal canal benign paroxysmal positional vertigo at the Dizziness Clinic of Seoul National University Bundang Hospital from May 2003 to February 2004 was performed. The directions of the nystagmus induced by lying down were compared with those determined by Ewald's second law. RESULTS: Of the 54 patients, 32 (20 apogeotropic and 12 geotropic) showed horizontal nystagmus induced by lying down. The nystagmus tended to be ipsilesional in apogeotropic patients (80%) and contralesional in their geotropic counterparts (75%). CONCLUSION: In horizontal canal benign paroxysmal positional vertigo, lying-down nystagmus mostly beats toward the involved ear in the apogeotropic type and directs to the healthy ear in the geotropic type. The direction of lying-down nystagmus may help lateralizing the involved ear in horizontal canal benign paroxysmal positional vertigo.     

水平半规管良性阵发性位置性眩晕的诊断

目的探讨水平半规管良性阵发性位置性眩晕（BPPV）的诊断。方法自2003年1月至2006年9月，本眩晕中心共确诊为水平半规管BPPV（HSC BPPV）患者46例。诊断依据为典型的病史及用红外视频眼震电图仪记录患者在Dix—Hallpike试验和滚转试验中的眼震结果，并排除其他疾病。研究HSC BPPV的眼震特点。结果441例诊断为BPPV患者中，46例（10．43％）为水平半规管BPPV。其中38例（82．61％）为单侧病变，5例（10．87％）患者合并同侧后半规管病变，3例（6．52％）为双侧病变。35例患者通过两种试验诱发出水平眼震，11例患者仅通过滚转试验诱发出水平眼震。25例患者眼震方向向地，13例患者眼震方向背地，3例患者眼震方向不固定，5例患者各种手法诱发出同一方向的眼震。29例患者在双侧手法中出现眼震，17例患者在一侧手法中出现眼震。结论HSC BPPV眼震为完全水平性且多为快相向地。通常受累耳在双侧手法中均可出现眼震，以向患侧为重。一侧水平半规管和后半规管可同时受累。滚转试验在HSC BPPV检查中比Dix—Hallpike试验更加敏感。Dix—Hallpike试验结合滚转试验可使更多的HSCBPPV患者得到确诊．     

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.     

水平背地性眼震良性阵发性位置性眩晕的诊断和手法复位

目的：验证一种新的用于治疗水平背地性眼震良性阵发性位置性眩晕（apogeotropicHSC—BPPV）的手法复位方法。方法：该研究采取改良的SupineRollTest（M-RollTest）方法共诊断出l78例水平半规管良性阵发性位置性眩晕（HSC-BPPV）患者,其中37例apogeotropicHSC—BPPV纳入该研究样本,占发病数的20．79％。采用管石重置手法先将37例apogeotropicHSC—BPPV患者水平背地性眼震转变为水平向地性眼震;此后,施行传统barbecue法进行手法复位。管石重置手法如下：①患者取仰卧头垫高30°体位静卧;②10min后头快速向患侧转90°;③2min后头向中线回旋45°;④保持体位2min后患者恢复仰卧头高30°体位;静卧10min后,采用M—RollTest检查验证患者是否出现双侧水平向地性眼震。如管石重置失败,重复以上手法多次,直至出现双侧水平向地性眼震为止。结果：36例双侧水平背地性眼震经水平背地性眼震管石重置手法全部转变为双侧不同强度的水平向地性眼震,其中,18例经1次,11例经2次,4例经3次,3例经4～6次。1例经1次管石重置手法后自觉症状减轻,再次行M—RollTest检查证明水平眼震消失,但Dix-hallpike手法复位检查出现同侧上跳性扭转性眼震,确诊为同侧后半规管良性阵发性位置性眩晕（PSC-BPPV）。该组管石重置成功率为为97．3％。36例HSC—BPPV患者经barbecue法手法复位全部一次性获得成功,1例PSC—BPPV患者经Eptey管石复位法一次性获得成功。结论：该研究设计的水平背地性管石重置手法是治疗apogeotropicHSC—BPPV的必要手段,简便易学、成功率高,患者舒适度好,相对依从性高。     

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.     

Persistent Direction-Fixed Nystagmus Following Canalith Repositioning Maneuver for Horizontal Canal BPPV: A Case of Canalith Jam

The authors report a 64-year-old man who developed persistent direction fixed nystagmus after a canalith repositioning maneuver for horizontal canal benign paroxysmal positional vertigo (HC-BPPV). The patient was initially diagnosed with right HC-BPPV given that the Dix-Hallpike test showed geotropic horizontal nystagmus that was more pronounced on the right side, although the roll test did not show any positional nystagmus. The patient was treated with a canalith repositioning maneuver (Lempert maneuver). The next day, the patient experienced a different character of dizziness, and left-beating spontaneous nystagmus regardless of head position was observed. After a forced prolonged left decubitus and frequent head shaking, his symptoms and nystagmus resolved. This condition, referred to as canalith jam, can be a complication after the repositioning maneuver in patients with BPPV. Atypical positional tests suggest that abnormal canal anatomy could be the underlying cause of canalith jam.     

不同类型良性阵发性位置性眩晕的诊断和治疗

目的探讨不同类型良性阵发性位置性眩晕（benign paroxysmal positional vertigo，BPPV）的诊断和治疗方法。方法对我科2004年4月-2006年3月就诊的BPPV病人131例．应用红外线视频眼动记录分析变位试验诱发的眼震特点，进行分型、定侧，并采用相应的耳石复位技术治疗。结果（1）后半规管BPPV94例（71．8％），随机分组采用Epley管石复位法和Semont管石解脱法各47例。（2）水平半规管BPPV29例（22．1％），水平向地性眼震者16例，另13例为水平背地性眼震者，自行或采用Gufoni疗法后转换为水平向地性9例，方向不能转换4例。采用barbecue翻滚和／或强迫侧卧体位疗法。（3）前半规管BPPV6例（4．6％），采用Epley管石复位法。（4）混合型BPPV2例（1．5％），行上述相应半规管的疗法。1周后随访总有效率85．5％（112／131），3个月后92.4％（121／131）。结论BPPV的诊断和治疗应根据不同变位试验诱发的眼震特征判别不同半规管及不同发病机理类型，并选择合适的耳石复位技术治疗。     

Management of 210 patients with benign paroxysmal positional vertigo: AMC protocol and outcomes

Conclusion: Benign paroxysmal positional vertigo (BPPV) could be treated with specific maneuvers for the involved canals. Management on a daily basis gave earlier relief than weekly treatment, especially in apogeotropic BPPV. Apogeotropic and multi-canal BPPVs were related to the increased numbers of follow-ups and trauma was related to the increased recurrence. Objective: We aimed to report the short-term outcomes of our protocol for BPPV and evaluate the factors influencing the results and recurrence. Methods: In 210 BPPV patients, posterior semicircular canal (PSCC), geotropic and apogeotropic lateral canal BPPVs were treated with the Epley maneuver, barbecue maneuver, and barbecue maneuver after head-shaking. The total number of follow-ups needed to have no provoked nystagmus, success rates at 1 week and 1 month, and factors for repeated maneuvers or recurrence were identified. Results: Apogeotropic and multi-canal BPPV needed more follow-ups than PSCC BPPV. Multi-canal BPPV showed a significantly lower 1-week success rate than other types. Anterior and multi-canal BPPV showed significantly lower 1-month success rates than other types. The 1-week success rates for PSCC and geotropic and apogeotropic BPPV in patients followed up on a daily basis were higher than those in patients with weekly follow-up and the difference was significant only in apogeotropic BPPV. The overall 1-year recurrence rate was 16% and higher recurrence rate was related to trauma.     

Sudden sensorineural hearing loss with positional vertigo: Initial findings of positional nystagmus and hearing outcomes

Objectives: To investigate the initial findings of positional nystagmus in patients with sudden sensorineural hearing loss (SSNHL) and positional vertigo, and to compare hearing improvement among patients with different types of positional nystagmus. Design: The characteristics of positional nystagmus upon initial examination were analysed, and the initial mean pure-tone audiometry (PTA) threshold was compared with that at three months after treatment. Study sample: Forty-four SSNHL patients with concomitant positional vertigo were included. Results: Positional nystagmus was classified into five subgroups; persistent geotropic direction-changing positional nystagmus (DCPN) in head-roll test (HRT) and negative Dix-Hallpike test (DHT), persistent apogeotropic DCPN in HRT and negative DHT, positive DHT and negative HRT, persistent geotropic DCPN in HRT and positive DHT, and persistent apogeotropic DCPN in HRT and positive DHT. PTA threshold improvement was significantly greater in SSNHL patients with negative DHT than with positive DHT (p?=?0.027). Conclusions: When geotropic DCPN was elicited by HRT, the nystagmus was persistent, which suggests that alteration of specific gravity of the endolymph, rather than the lateral canal canalolithiasis, may be a cause of this characteristic positional nystagmus. Positive DTH may be a prognostic factor for worse hearing recovery among patients with SSNHL and positional vertigo.     

Clinical characteristics of patients with multi-canal benign paroxysmal positional vertigo

IntroductionMulti-canal benign paroxysmal positional vertigo is considered to be a rare and controversial type in the new diagnostic guidelines of Bárány because the nystagmus is more complicated or atypical, which is worthy of further study.ObjectiveBased on the diagnostic criteria for multi-canal benign paroxysmal positional vertigo proposed by International Bárány Society, the study aimed to investigate the clinical characteristics, diagnosis and treatment of multi-canal benign paroxysmal positional vertigo.MethodsA total of 41 patients with multi-canal benign paroxysmal positional vertigo were included and diagnosed by Roll, Dix-Hallpike and straight head hanging tests. Manual reduction was performed according to the involvement of semicircular canals.ResultsAmong the 41 cases, 19 (46.3%) patients showed vertical up-beating nystagmus with or without torsional component and geotropic, apogeotropic horizontal nystagmus, and were diagnosed with posterior-horizontal canal. 11 (26.8%) patients showed vertical up-beating nystagmus with torsional component on one side and vertical down-beating nystagmus with or without torsional component on the other side during Dix-Hallpike test or straight head hanging test and were diagnosed with posterior-anterior canal benign paroxysmal positional vertigo 9 (26.8%) patients showed vertical down-beating nystagmus with or without torsional component and geotropic, apogeotropic horizontal nystagmus, and were diagnosed with anterior-horizontal canal 2 (4.9%) patients showed vertical geotropic torsional up-beating nystagmus on both sides and were diagnosed with bilateral posterior canal benign paroxysmal positional vertigo. High correlation between the sides with reduced vestibular function or hearing loss and the side affected by Multi-canal benign paroxysmal positional vertigo was revealed (contingency coefficient = 0.602, p = 0.010). During one-week follow up, nystagmus/vertigo has been significantly alleviated or disappeared in 87.8% (36/41) patients.ConclusionPosterior-horizontal canal benign paroxysmal positional vertigo was the most common type. Multi-canal benign paroxysmal positional vertigo involving anterior canal was also not uncommon. Caloric tests and pure tone audiometry may help in the determination of the affected side. Manual reduction was effective in most of Multi-canal benign paroxysmal positional vertigo patients.     

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.     

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.     

Treatment of benign positional vertigo in the elderly: a randomized trial

OBJECTIVES/HYPOTHESIS: The objective of the study was to evaluate the efficacy of three therapeutic strategies (Semont maneuver, flunarizine, and no treatment) in patients with benign paroxysmal positional vertigo. STUDY DESIGN: Randomized prospective trial. METHODS: One hundred fifty-six consecutive patients older than 60 years of age who were affected by benign paroxysmal positional vertigo of the posterior semicircular canal were enrolled. The diagnosis was made on the basis of the history of recurrent sudden crisis of vertigo and positional-induced typical nystagmus after Dix-Hallpike positioning maneuver. Patients were randomly allocated to receive Semont liberatory maneuver (intended as a statoconia-detachment maneuver), flunarizine, or no treatment. A post-treatment negative Dix-Hallpike test result was considered as a proof of vertigo resolution. RESULTS: Cure rates with Semont maneuver were significantly higher (94.2%) than those obtained with flunarizine (57.7%) and no treatment (36.4%) (P <.001). Within a 6-month follow-up, relapse rates were lower among patients treated with Semont maneuver (3.8%) than those obtained with flunarizine (5.8%) and no treatment (21.1%). All patients with resolution of symptoms and negative Dix-Hallpike test results showed a great improvement in daily activities and quality of life (P <.001). CONCLUSION: Semont liberatory maneuver is the most successful therapy for benign paroxysmal positional vertigo and improves patients' quality of life. Diagnostic and therapeutic maneuvers are easy to perform and should be part of the medical knowledge of every general practitioner and geriatrician.     

Conversion between geotropic and apogeotropic persistent direction-changing positional nystagmus

Conclusion: Clinical features in the course of conversion differed between patients with SSNHL and cupulopathy, which indicates that the pathophysiology of persistent geotropic or apogeotropic DCPN and the mechanism of the change in nystagmus direction may differ between the two groups. Objective: The aim of this study is to investigate clinical characteristics of 10 patients with persistent DCPN who exhibited a conversion of nystagmus direction between geotropic and apogeotropic, and discuss possible mechanisms. Methods: Using video-oculography, serial examinations of nystagmus in a head-roll test were performed. Results: Of these 10 patients, five had sudden sensorineural hearing loss (SSNHL) and the remaining five had cupulopathy. In SSNHL, direction of nystagmus changed from geotropic to apogeotropic in three patients and from apogeotropic to geotropic in two patients. In cupulopathy, persistent apogeotropic DCPN always preceded persistent geotropic DCPN. The change in nystagmus direction occurred earlier in patients with cupulopathy (1 or 2 days after vertigo onset) than in patients with SSNHL (4–23 days after vertigo onset). While the null plane was consistently identified on one side, regardless of the nystagmus direction in cupulopathy, it was not always identified on the side of hearing loss in SSNHL.     

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.     

A prospective randomized controlled study of Li quick repositioning maneuver for geotropic horizontal canal BPPV

Background: Li quick repositioning maneuver for treatment of geotropic horizontal canal benign paroxysmal positional vertigo (HC-BPPV) was reported in the literature.

Objective: The aim of this study is to observe the clinical efficacy of the Li quick repositioning maneuver for the treatment of geotropic HC-BPPV.

Methods: The single-blind method was used to conduct a prospective controlled study on 120 patients with geotropic HC-BPPV from May 2014 to May 2017. Patients were randomly assigned to the Li quick repositioning maneuver (Li maneuver) group or the barbecue repositioning maneuver (barbecue maneuver) group.

Results: The successful repositioning rates were 53.3%, 70.4%, 90.7% and 92.3%, respectively, in barbecue maneuver group and 61.7%, 80.7%, 93.0% and 96.3%, respectively, in Li maneuver group at 1-day, 3-day, 1-week and 1-month follow-up. Differences in success rates of repositioning between Li and barbecue maneuver groups at 1?day, 3 days, 1 week and 1 month after initial treatment were not statistically significant using the Kaplan–Meier survival curve with a log-rank test (p?=?.270) .

Conclusion: The Li maneuver is a rapid, simple and efficacious repositioning method for geotropic HC-BPPV and can be widely applied in clinical practice as an alternative method.     

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.