Dynamics of the vestibulo-ocular reflex in patients with the horizontal semicircular canal variant of benign paroxysmal positional vertigo

Objective Two types of direction-changing positional nystagmus, the geotropic and apogeotropic variants, are observed in patients with the horizontal semicircular canal (HSCC) type of benign paroxysmal positional vertigo (H-BPPV). In this study, we assessed the dynamics of the vestibulo-ocular reflex (VOR) of the HSCC in patients with H-BPPV.

Material and Methods Patients were rotated about the earth-vertical axis at frequencies of 0.1, 0.3, 0.5, 0.7 and 1.0 Hz with a maximum angular velocity of 50°/s. Eye movements were recorded on a video imaging system using an infrared charge-coupled device (CCD) camera, and our new technique for analyzing the rotation vector of eye movements in three dimensions was used.

Results In the patients with geotropic positional nystagmus, there were no differences in VOR gain between rotation to the affected and unaffected sides at frequencies of 0.1–1.0 Hz. Although no differences in VOR gain at frequencies of 0.3–1.0 Hz were noticed in patients with apogeotropic positional nystagmus, the VOR gain at 0.1 Hz was significantly smaller on rotation to the affected compared to the unaffected side.

Conclusion The results indicate that cupulolithiasis in the HSCC affected the dynamics of the HSCC-ocular reflex at 0.1 Hz, but not at higher frequencies, and that canalolithiasis in the HSCC does not change the VOR gain of the HSCC at any frequency. It is suggested that cupulolithiasis causes transient impairment of HSCC function by means of its mechanical restriction of movements of the cupula.     

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.     

继发性后半规管良性阵发性位置性眩晕的诊治

目的 探讨继发性良性阵发性位置性眩晕(BPPV)的诊断和治疗。方法研究继发性后半规管BPPV的内耳疾病6例病历资料,诊断依据为病史及Dix-Hallpike试验诱导出现的眼震结果。结果 6例内耳疾病(分别为突发性聋3例, 梅尼埃病2例, 前庭神经元炎1例)伴有后半规管良性阵发性位置性眩晕被确诊,通过Dix-Hallpike试验诱发出垂直扭转型眼震。结论 继发性BPPV临床较少见,常为后半规管受累,通过Dix-Hallpike试验和Epley手法复位可以确诊和治愈。     

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。     

Spontaneous nystagmus in horizontal canal benign paroxysmal positional vertigo

Objective

Benign paroxysmal positional vertigo of horizontal semicircular canal (HSC-BPPV) is characterized by either geotropic or apogeotropic nystagmus induced by head roll test. Some patients also present with spontaneous nystagmus. The aim of this study is to examine the clinical manifestation of spontaneous nystagmus in HSC-BPPV and evaluate the effect on the treatment outcome.

Patients and methods

Electronystagmography and video eye movement recordings of 125 patients diagnosed as HSC-BPPV were reviewed retrospectively. Presence of spontaneous nystagmus was analyzed and treatment outcome after repositioning therapy was compared.

Results

Overall, spontaneous nystagmus was observed in 19 patients (15.2%) with HSC-BPPV at initial presentation. In canalolithiasis group (n = 64), the treatment outcome did not differ between patients with or without spontaneous nystagmus. However, in cupulolithiasis group (n = 61), patients presenting with spontaneous nystagmus (n = 10) required more repositioning therapy sessions.

Conclusion

The presence of spontaneous nystagmus at initial presentation may implicate poorer treatment outcome in cupulolithiasis HSC-BPPV patients.     

Purely vertical upbeat nystagmus in bilateral posterior canal benign paroxysmal positional vertigo: A case report

Vertical nystagmus occurs in patients with central vestibular system pathology. Lesions of the pons, medulla, and cerebellum lead to vertical nystagmus. Given this association, vertical nystagmus is considered pathognomonic in nature. We present a case of benign paroxysmal positional vertigo (BPPV) with positive Dix‐Hallpike bilaterally, but also with upbeat purely vertical nystagmus in the straight back head hanging position. Computed tomography imaging of the typically pathologic structures in vertical nystagmus (brainstem/posterior fossa) revealed normal anatomy. We propose this case as an instance of peripheral‐associated purely vertical nystagmus without central pathology, while building on our previous understanding of BPPV physiology. Laryngoscope, 2010     

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．     

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.     

Contralateral incipient posterior canal benign positional paroxysmal vertigo: complication after Epley maneuver

Background: Particle repositioning procedures give consistent results for the treatment of benign positional paroxysmal vertigo (BPPV). However, little consideration has been given to the possibilities of bilateral disease. Objective/Hypothesis: To report contralateral symptoms and signs suggestive of revealed or incipient BPPV as a complication of Epley maneuver. Study Design: A prospective cohort of 198 cases over a period of 11 years. Results: Ten (5.0%) developed contralateral symptoms and signs suggestive of revealed or incipient posterior canal BPPV within 2 weeks of treatment. Conclusion: This novel observation has not been previously described and may influence the strategy for future management of patients with BPPV. Particle repositioning maneuvers for the previously asymptomatic contralateral ear may need to be considered in a subset of patients with posterior canal BPPV who suffer contralateral symptoms after undergoing treatment for the original ear.     

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.     

Pseudo-Spontaneous Nystagmus in Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo

Objectives

Spontaneous nystagmus, which has been considered a typical sign of acute vestibulopathy, has recently been reported in benign paroxysmal positional vertigo involving the lateral semicircular canals (LC-BPPV) without unilateral vestibulopathy (pseudo-spontaneous nystagmus, PSN), but research about its clinical application is still limited. Here we investigate the frequency and characteristics of PSN in LC-BPPV patients, and estimate its prognostic value.

Methods

For 95 patients with LC-BPPV, we examined nystagmus in the sitting position in the clinic with video goggles. Patients were categorized as PSN or non-PSN, according to presence of horizontal nystagmus in the sitting position at diagnosis. The duration of vertiginous symptoms before diagnosis and the duration of treatment were compared between the two groups. The results of video-nystagmography test were reviewed when available.

Results

PSN was examined in 16 (16.8%) patients, all of whose symptoms disappeared immediately after successful repositioning therapy. While the duration of symptoms did not differ statistically between groups (P=0.481), the duration of treatment in the PSN group was significantly longer than in the non-PSN group (P<0.001).

Conclusion

We conclude that the presence of spontaneous nystagmus in the sitting position does not preclude a diagnosis of LC-BPPV without unilateral vestibulopathy. PSN was related to a poor outcome of LC-BPPV in this study.     

特发性水平半规管良性阵发性位置性眩晕复发相关因素分析

目的 研究特发性水平半规管良性阵发性位置性眩晕(HSC-BPPV)复位次数、前庭冷热试验、复位后残余眩晕是否与复发率存在关系。方法 2016年1月—2018年1月门诊手法复位成功的84例特发性HSC-BPPV的患者纳入本研究,所有患者均行Barbecue滚转手法复位。根据复位次数分为A组(<3次)和B组(≥3次);根据患者复位后有无残余眩晕,分为C组(无残余眩晕)和D组(残余眩晕),观察复发率。所有患者均行前庭冷热试验检查。结果 本研究显示A组(20.9%)与B组(26.8%)的复发率无明显差异;C组(11.8%)与D组(32.0%)复发率差异具有统计学意义(P=0.033);复位后存在残余眩晕患者前庭功能异常率高;复位后存在残余眩晕并伴有前庭冷热试验异常的患者复发率最高(66.7%);复发率最低的为复位次数<3次且复位后无残余眩晕的患者(6.3%)。结论 HSC-BPPV复发率与复位次数无关,冷热试验异常与残存眩晕相关,复位后残余眩晕伴前庭冷热试验异常提示患者复发率增高。     

42例轻嵴帽患者的眼震特点及临床疗效分析

目的 对轻嵴帽患者的眼震特点及临床疗效进行分析。方法 收集2018年1月—至2021年1月就诊于晋中市第一人民医院耳鼻咽喉科眩晕门诊并确诊为轻嵴帽患者42例为研究对象,通过视频眼震电图记录并分析其眼震数据,全部患者均给予Barbecue法复位治疗及复位后予口服药物治疗,评价即时、1周后及1个月后疗效。结果 42例患者中继发于突发性耳聋2例(4.8%),出现直立位自发性眼震10例(23.8%),仰卧位眼震24例(57.1%),眼震均朝向健侧,并出现眼震消失平面即第二零平面,且位于患侧。所有患者双侧转头位均出现持续性向地性位置性眼震,平均持续时间＞1 min,平均慢相角速度(SPV)＞20°/s,且无明显潜伏期,治疗后即时痊愈0例,改善5例(11.9%),无效37例(88.1%)。1周后痊愈2例(4.8%),改善18例(42.9%),无效22例(52.4%);1个月后痊愈39例(92.9%),改善3例(7.1%),无效0例。即时疗效、1周后疗效及1个月后疗效比较差异具有统计学意义(P＜0.05);年龄与即时疗效相关(P＜0.05);患侧眼震强度与1周后疗效相关(P＜0.05),患侧眼震强度及持续时间与1个月后疗效相关(P＜0.05)。结论 轻嵴帽眼震特点表现为持续性向地性位置性,持续时间长,且无潜伏期,部分可出现零平面,并伴随仰卧位眼震发生。该疾病具有一定自愈性,预后良好。年龄、患侧眼震强度、时长对患者的预后有影响,年龄小、眼震强度弱且眼震持续时间短的患者疗效相对较好。     

A new treatment (the affected-ear-up 90° maneuver) for benign paroxysmal positional vertigo of the lateral semicircular canal

Background: Although several researchers have tried various kinds of canalith repositioning procedures for lateral canalolithiasis, a standard treatment has not been established. We have adopted 90° rotation, which is anatomically appropriate.

Objective: To clarify the efficacy of the affected-ear-up 90° maneuver.

Materials and methods: The subjects were 23 consecutive patients (15 females, 8 males) who revealed transient direction-changing geotropic positional nystagmus. After determining the affected side, we immediately performed the canalith repositioning procedure. To perform this maneuver: (1) Place the patient in the supine position. (2) Rotate the head toward the healthy side until 90° from the supine. (3) Sit up. (4) Ask the patient to remain upright with the chin down until going to bed.

Results: Nineteen patients (83%) became symptom-free by only one maneuver. However, three patients converted to ipsilateral cupulolithiasis of the lateral canal, and one patient required a second maneuver.

Conclusion: The affected-ear-up 90° maneuver is effective against lateral canalolithiasis.     

New scoring system of an interview for the diagnosis of benign paroxysmal positional vertigo

Conclusion This study investigated a novel instrument to diagnose benign paroxysmal positional vertigo (BPPV).

Objective To develop a new scoring system of an interview for the diagnosis of BPPV.

Methods The answers to questions on dizziness and/or vertigo (D/V) (571 patients) were analyzed and the questions for which the answers differed significantly between the patients with and without BPPV were selected.

Results This study established an intensive questionnaire with a scoring system. It consists of the following questions: (1) Is rotary vertigo a characteristic of your D/V? (2) Is your D/V triggered when you roll your head over in a supine position? (3) Does your D/V disappear within 5 min? (4) Have you previously experienced hearing loss in one ear, or have you experienced hearing loss, tinnitus, or ear fullness with this D/V? One point each was given to an answer of ‘yes’ to questions (1) and (2). Two points were given to an answer of ‘yes’ to question (3). One point was subtracted upon an answer of ‘yes’ to question (4). When the total score was greater than two points, the patient was diagnosed with BPPV. The sensitivity of the diagnosis of BPPV by this scoring system was 81% and the specificity was 69%.     

Comparison between objective and subjective benign paroxysmal positional vertigo: clinical features and outcomes

Conclusions: Objective benign paroxysmal positional vertigo (O-BPPV) and subjective BPPV (S-BPPV) have similar demographic and clinical features. Canalith repositioning manoeuvres (CRMs) can be an effective treatment for patients with S-BPPV, and a diagnosis of positional nystagmus is not essential for considering CRMs. This study supports the use of CRMs as the primary treatment for S-BPPV.

Objective: To examine differences in demographic and clinical features, as well as treatment outcomes, between O-BPPV and S-BPPV.

Methods: The medical records of 134 patients with BPPV were reviewed for demographic characteristics, past medical history, associated symptoms, response to CRMs, interval between symptom onset and the first medical visit, and recurrence rate. The O-BPPV group (n?=?101) comprised patients who experienced vertigo and accompanying autonomic symptoms, and showed typical nystagmus. The S-BPPV group (n?=?33) comprised patients who, when subjected to a provoking manoeuvre, showed all of the classic BPPV symptoms but did not show nystagmus. All patients had at least 3 years of follow-up.

Results: The demographics (age and sex ratio), past medical history, and associated symptoms were not significantly different between the two groups. Posterior semi-circular canal BPPV appeared more than twice as often as horizontal semi-circular canal BPPV in patients with S-BPPV. However, both canals were affected to a similar proportion in patients with O-BPPV, and the difference was marginally significant (p?=?0.073). Overall improvement was better in O-BPPV than in S-BPPV; however, there was no significant difference. The total numbers of manoeuvres for recovery and the interval between symptom onset and the first medical visit also did not show any significant inter-group differences. During a 3-year follow-up, the recurrence rate was 13.8% for O-BPPV and 21.2% for S-BPPV.     

后半规管良性阵发性位置性眩晕急性发作时的临床表现

目的 观察和总结后半规管良性阵发性位置性眩晕(PSC-BPPV)急性发作时的临床特征,为临床诊断提供依据。 方法 回顾性分析115例PSC-BPPV患者急性发作时的临床表现,分析并总结患者的性别和年龄分布、发病时状态、头晕性质、眩晕发作与头部活动间的关系、眼震、伴随症状、辅助检查等临床特征。 结果 PSC-BPPV急性发作时的临床表现具有以下特征:(1)女性多于男性;(2)易累及50岁以上人群;(3)在起床、躺卧、翻身或活动中头部主动或被动到某一位置时突然发病,特别是晨起发病居多;(4)剧烈的眩晕伴有恶心、呕吐;(5)部分患者在初次查体时表现出旋转性眼震;(6)不伴有耳蜗和神经系统症状和体征;(7)颅脑影像学检查无阳性相关发现。 结论 急诊时如患者在起床、躺下、翻身或头部活动到某一位置时突然出现剧烈的眩晕发作,不伴有耳蜗和神经系统症状体征,颅脑影像学检查无相关阳性发现,应当考虑PSC-BPPV的诊断,及早行Dix-Hallpke诱发试验能够确立诊断。