Revisiting benign paroxysmal positional vertigo pathophysiology

Benign paroxysmal positional vertigo is the most common peripheral cause of vertigo. Although its pathophysiologic mechanisms remain unclear, different locations have been attributed throughout the last century, from the days of Bárány. Disease was initially located by Dix and Hallpike in the utricle, but later, Schuknecht's works elicited the cupulolithiasis and canalolithiasis theories, localizing the pathology to the semicircular canal system and mainly to the posterior one. However, conflicting evidences from temporal bone studies accumulated against this theory, which suggest other explanations. Although this clinical entity is well defined, and can usually be effectively treated with certain physical maneuvers, its pathophysiology is still obscure and is being critically discussed in this article, which reviews the milestones of benign paroxysmal positional vertigo understanding.     

继发于突发性聋的BPPV与原发性BPPV的疗效和转归比较

目的 回顾性分析继发于突发性聋的良性阵发性位置性眩晕(BPPV)与原发性BPPV的临床特点,比较两者疗效和转归,并分析可能的原因。方法 观察2019年12月—2021年12月就诊的突发性聋继发BPPV患者74例,与同期就诊的原发性BPPV患者112例进行比较。观察、比较突聋继发BPPV患者与原发性BPPV患者的临床分型、疗效、治疗后眩晕障碍量表(DHI)评分、治疗前血同型半胱氨酸(Hcy)数值的差异。结果 原发组中单管管石症80.4%(90/112),高于继发组33.8%(25/74),两者比较差异具有统计学意义(χ²=40.953,P<0.01);原发组1次治愈率86.6%(97/112),高于继发组50.0%(37/74),两者比较差异具有统计学意义(χ²=29.467,P<0.01);继发组1次治愈后眼震慢相速度CP值>20%为67.6%(25/37),高于原发组25.8%(25/97),两者比较差异具有统计学意义(χ²=20.002,P<0.01)。继发组治疗后DHI评分≤30分为31.1...     

Stapedotomy and post-operative benign paroxysmal positional vertigo

In our experience some patients subjected to stapedotomy presented vestibular symptoms characterized by brief episodes of vertigo that only lasted 10 to 20 seconds, accompanied by rapid paroxysmal nystagmus similar to that found in benign paroxysmal positional vertigo (BPPV). For this study, 141 otosclerotic patients were enroled and underwent stapedotomy following the Fisch and Dillier's technique. Twelve out (8.5%) of all the patients under study complained of post-operative vertigo and the physical examination of the positional nystagmus confirmed the presence of paroxymal positional vertigo. The percentage seems particularly high and does not agree with the data reported in literature. The onset of the vestibular symptoms appeared between the 5th and 21st day after surgery. To our knowledge, this is the first prospective study existing in literature on the incidence of BPPV after surgery of the stapes. It must also be stressed that the patient should be informed beforehand during the consultation phase of the possibility of post-stapedotomy BPPV together with the other causes of post-operative vertigo.     

水平半规管良性阵发性位置性眩晕

良性阵发性位置性眩晕(Benign Paroxysm Positional Vertigo,BPPV)是一种阵发性、由头位变动引起的伴有特征性眼震的短暂发作性眩晕,是最常见的前庭疾病。后半规管BPPV(Benign Paroxysmal Positional Vertigo ofPosterior Semicircular Canal,PSC-BPPV)是最常见的BPPV类型,临床上推荐Dix-Hallpike试验作为诊断PSC-BPPV的"金标准",Epley法是目前治疗PSC-BPPV最有效的复位方法。水平半规管BPPV(Benign Paroxysmal Positional Vertigoof Horizontal Semicircular Canal,HSC-BPPV)发病机制复杂,是仅次于PSC-BPPV的常见BPPV亚型,其实际发病率可能被低估。临床实践中,HSC-BPPV其诊断与复位治疗方法与PSC-BPPV均不相同。本文即围绕HSC-BPPV研究的发展史及流行病学、分类、病因、发病机制、诊断及治疗复位方法的相关进展做一综述。     

良性阵发性位置性眩晕的临床分析

目的探讨良性阵发性位置性眩晕的临床特征。方法回顾160例确诊BPPV患者,分析其临床资料。结果BPPV发病年龄为7-82岁,好发年龄段均为50—70岁,男女比例为0．68：1。发生于后半规管的BPPV为113例（70．6％）,水平半规管为21例（13．1％）,有26例（16．3％）为同时发生于后半规管和外侧半规管。47例水平半规管BPPV中,33例（70．2％）为半规管耳石,14例（29．8％）为壶腹嵴顶耳石。确诊患者中,有98例（61．3％）为首次发作,有49例（30．6％）为复发,或者有明确的类似发作病史。13例（8．1％）曾有眩晕发作,但具体发病特征不明确。对P—BPPV以Epley复位,1周后复查有效率为81．4％（92／113）。半规管型H—BPPV以Lempert法复位,有效率为72．7％（24／33）。壶腹嵴顶型H—BPPV采用强迫体位（健侧卧位）治疗,1周后复查有38．5％（5／13）转为半规管型,以Lempert法复位奏效。随访1月有12例复发（9例P—BPPV和3例H—BPPV）。结论BPPv在各年龄段均有发作,通过患者的发病特征和详细的神经耳科学检查可以做出诊断。根据不同类型进行复位治疗可以取得较好的疗效。     

良性阵发性位置性眩晕临床特点

目的分析良性阵发性位置性眩晕（benign paroxysmal positional vertigo,BPPV）患者临床特点。方法 2009年9月～2010年6月明确诊断BPPV的患者90例,详细记录病史、伴随症状、既往史,进行耳科常规检查、纯音听力测试和前庭功能检查,使用视频眼震图观察记录视动功能试验、冷热试验、水平滚转试验、变位试验等,计算半规管轻瘫（canal paresis,CP）值。结果①患者平均年龄（52.48±15.43）岁,男女比例为1∶2.1;耳鼻咽喉科首诊36例（40.0%）、神经内科首诊31例（34.4%）。②后半规管BPPV 51例（56.7%）,水平半规管BPPV 18例（20.0%）,上半规管BPPV 20例（22.2%）,混合型BPPV 1例（1.1%）。③行前庭功能检查78例患者中有52例（66.7%）出现CP,当病史≤2周、2周〈病史≤1个月、1个月〈病史≤6个月、6个月〈病史≤5年、病史〉5年,CP所占比例分别为42.9%、61.5%、75.0%、84.2%、62.5%,P〉0.05,不具有统计学意义。77例单侧BPPV患者中,患侧CP25例（32.5%）,健侧CP11例（14.3%）,双侧CP15例（19.5%）。④行纯音听力测试,67例BPPV患者（68耳）中有21例（21耳,30.9%）伴有感音神经性听力损失。结论 BPPV是常见的前庭系统疾病,病因尚不明确。可伴有前庭功能异常和感音神经性聋,临床上应重视对BPPV患者前庭功能和听功能评价,以明确相关的防治策略。     

Pathology of benign paroxysmal positional vertigo revisited

The pathophysiology of benign paroxysmal positional vertigo (BPPV) is not completely understood. Although the concept of degenerated otoconia transforming the posterior canal (PC) crista into a gravity-sensitive sense organ has gained popular support, several temporal bone (TB) series have revealed similar deposits in normal TBs, suggesting they are a normal change in the aging labyrinth. Furthermore, some TBs from patients with BPPV do not contain particles in the posterior canal. Five TBs from patients with BPPV were studied quantitatively and qualitatively. A small PC cupular deposit was found in 1 TB, while none was seen in the other 4 TBs. The major pathological changes were 1) a 50% loss of ganglion cells in the superior vestibular division of all 5 TBs and 2) a 50% loss of neurons in the inferior division of 3 TBs, and a 30% loss in 2 TBs that contained abnormal saccular ganglion cells. These observations support a concept in the pathophysiology of BPPV that includes loss of the inhibitory effect of otolith organs on canal sense organs.     

良性阵发性位置性眩晕预后分析

目的探讨管石复位法（canalith repositioning procedure,CRP）治疗良性阵发性位置性眩晕（benign paroxysmal positional vertigo,BPPV）的预后因素。方法回顾性分析115例后半规管BPPV患者的治疗和随访结果 ,研究发病因素与疗效的关系。结果 特发性BPPV患者1次CRP治疗成功率和复发率为77.8%和11.1%,伴有梅尼埃病的BPPV患者分别为27.8%和44.4%,有偏头痛及脑卒中病史的BPPV患者分别为26.7%和40.0%,与特发性BPPV患者相比差异均有统计学意义（P〈0.05）。结论 BPPV的预后和梅尼埃病、偏头痛及脑卒中病史密切相关。     

Our experience with benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo has been considered a separate nosological entity. This status is explained by the theories of cupulolithiasis and canalolithiasis. The disorder is treated with training; success was achieved in 88% of our cases, which correlates with the literary data. Trauma and inflammation in the head and neck region may be regarded as possible etiological factors.     

Spontaneous nystagmus in benign paroxysmal positional vertigo

Objective

The purpose of this study was to evaluate the presence and eventually to study the features of spontaneous nystagmus (Ny) in our patients with diagnosis of benign paroxysmal positional vertigo (BPPV).

Patients and methods

We retrospectively reviewed the clinical records of patients who presented with vertigo spells and were managed at our tertiary care referral center. Patients with only idiopathic BPPV presenting with typical vertigo spells and positioning Ny characteristic of the disease were included in this study. To investigate the positioning Ny, we studied the patients in the sitting position, during the head shaking test, and during the Dix-Hallpike test and the McClure-Pagnini test (Ny provoked by rotation of the head in a supine patient). Ny responses in all patients were observed using infrared videoscopy.

Results

We managed 412 patients affected by BPPV. Of the 412 patients, 292 (70.87%) were diagnosed to be having posterior canal-BPPV and 110 (26.99%) patients had horizontal canal-BPPV (HC-BPPV). The remaining 10 patients (2.44%) were identified to have anterior canal-BPPV. Spontaneous Ny in sitting position was observed, by infrared videoscopy, only in the patients affected by HC-BPPV.

Conclusion

Spontaneous Ny in BPPV can be observed with infrared videoscopy in patients affected by HC-BPPV. The origin of this Ny is most likely due to a natural inclination of horizontal semicircular canal with respect to the horizontal plane. This Ny stops after flexion of the head in neutral position, and for this reason, it should be considered as a seemingly spontaneous Ny. This Ny, in our experience, is observed in most HC-BPPV patients but does not indicate the need for a different management protocol or any different prognostic value of HC-BPPV.     

Clinical features of benign paroxysmal positional vertigo

Our understanding of the pathomechanism of benign paroxysmal positional vertigo (BPPV) has improved dramatically. A type of BPPV featuring mixed torsional and vertical nystagmus induced by the Dix-Hallpike maneuver involves the posterior semicircular canal (P-BPPV). The other type of BPPV featuring horizontal nystagmus induced by spine-to-lateral head positioning involves the horizontal canal BPPV (H-BPPV). In complaints of vertigo or dizziness, 619 patients visited our department last year. Of these, 142 (23%) was had positional nystagmus consistent with a diagnosis of BPPV, 118 (19%) had no nystagmus but were suspected of BPPV due to vertigo episodes. BPPV was the most frequent diagnosis. H-BPPV was not rare, but accounted for 30% of BPPV. Of H-BPPV, 73% featured direction changing geotropic nystagmus, and 27% direction changing apogeotropic nystagmus. H-BPPV resolved faster than P-BPPV. Most cases caused by head trauma were P-BPPV. Transition between P- and H-BPPV was found in 6 cases. Women outnumbered men by about 3 to 2 in both P- and H-BPPV. Peak incidence was found in the those in their 60s and 70s, suggesting that the etiologies of both types of BPPV are essentially the same.     

Onset time of benign paroxysmal positional vertigo

Conclusion: Benign paroxysmal positional vertigo (BPPV) is strongly related to sleep. This study proposes a micro-otoconia accumulation theory in which the pathological debris is an aggregate of micro-otoconia over a long time period, and which begins to slide by its own weight during sleep.

Objectives: To examine the onset time of idiopathic BPPV and to investigate its etiology.

Method: Patients (n?=?351) were classified as posterior canalolithiasis (PC), horizontal canalolithiasis (HC), and horizontal heavy cupula (HHC) according to nystagmus findings. This study examined the medical records, and categorized the onset times into the following four groups; (1) during sleep, (2) at the time of rising, (3) morning, and (4) afternoon.

Results: PC (n?=?135): In 33 patients, vertigo occurred during sleep, in 69 patients at rising, in 10 patients in the morning, and in 23 patients in the afternoon. HC (n?=?87): In 38 patients, vertigo occurred during sleep, in 30 patients at rising, in eight patients in the morning, and in 11 patients in the afternoon. HHC (n?=?129): In 27 patients, vertigo occurred during sleep, in 59 patients at rising, in 15 patients in the morning, and in 28 patients in the afternoon.     

Electronystagmographic findings in benign paroxysmal positional vertigo

The aim of this study was to investigate the electronystagmographic findings in patients with benign paroxysmal positional vertigo. A retrospective review of the records of 168 patients with this disease during the past 3 years was performed. Epidemiological data and results from the audiological and neuro-otologic workup, including electronystagmography, were recorded. One hundred fifty-one patients had involvement of the posterior canal, 14 of the horizontal canal, and 3 of the anterior canal. Seventy-two patients (42.8%) had abnormal findings on the caloric tests. Thirty-seven of them (22%) had canal paresis and 23 (13.7%) had directional preponderance, whereas in 12 patients (7.1%) both unilateral weakness and directional preponderance were found. Finally, 21 patients (12.5%) had spontaneous nystagmus. It may be thus concluded that electronystagmographic abnormalities are quite common in patients with benign paroxysmal positional vertigo. Their presence may be explained according to several mechanisms, which are further discussed herein.     

Strategies to prevent recurrence of benign paroxysmal positional vertigo

OBJECTIVE: To determine if a daily routine of Brandt-Daroff exercises increases the time to recurrence and reduces the rate of recurrence of benign paroxysmal positional vertigo (BPPV). DESIGN: Random sample of convenience and retrospective case review. SETTING: Tertiary referral center and outpatient clinic. PATIENTS: One hundred sixteen patients diagnosed with BPPV involving the posterior semicircular canal (BPPV-PC) who were successfully treated with the canalith repositioning procedure. INTERVENTIONS: Patients in the treatment group (n = 43) performed daily Brandt-Daroff exercises, while patients in the no-treatment group (n = 73) performed no exercises. MAIN OUTCOME MEASURES: Follow-up was as long as 2 years. Every 2 months patients were mailed a questionnaire. If BPPV had recurred, patients contacted the principal investigator within 24 hours. Within 1 to 2 weeks, patients were evaluated in the clinic with the Dix-Hallpike maneuver or, if unable to travel to the clinic, interviewed by telephone. RESULTS: Symptoms recurred in 50 (43%) of the 116 subjects, 34 (47%) of 73 in the no-treatment group and 16 (37%) of 43 in the treatment group. There was no significant difference in the frequency of recurrence (Pearson chi(2), P = .33) or time to recurrence (survival analysis, log-rank test, P = .92). A history of recurrent BPPV-PC did not affect frequency of recurrence (Pearson chi(2), P = .33) or time to recurrence (survival analysis, log-rank test, P = .72). CONCLUSION: Our results suggest that a daily routine of Brandt-Daroff exercises does not significantly affect the time to recurrence or the rate of recurrence of BPPV-PC.