Research in Vestibular Science

Original Articles

Saccadic oscillations as a possible indicator of dizziness due to choline esterase inhibitors: an observational study with video-oculography: Ileok Jung, Moon-Ho Park, Ji-Soo Kim; Res Vestib Sci. 2024;23(3):101-105. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.015

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Abstract PDF Supplementary Material: Introduction: Cholinesterase inhibitors (ChEIs) are widely used to treat mild to moderate Alzheimer disease and vascular dementia. Even though dizziness due to medication of ChEIs has been ascribed to adverse effects on the cardiovascular or central nervous system, the mechanisms remain unclear and objective indicators are not available.
Methods
We recorded the eye movements using video-oculography in three patients who developed dizziness and unsteadiness after initiation or increment of ChEI, donepezil (Aricept).
Results
The patients showed frequent saccadic oscillations that improved after discontinuation of ChEI.
Conclusions
Frequent saccadic oscillations may be an indicator of dizziness in patients taking ChEIs.

Comparison of the outcomes of treatment with an oral diuretics with steroid and steroid only for acute low-tone hearing loss: a prospective randomized controlled trial: Seok Min Hong, Yeso Choi, Sung Min Park, Jae Yong Byun; Res Vestib Sci. 2024;23(3):95-100. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.012

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Abstract PDF: Objectives
This study aimed to compare the efficacy of a combined steroid and diuretic (isosorbide) treatment with that of steroid-only treatment in patients with acute low-tone sensorineural hearing loss (ALHL).
Methods
A total of 34 patients with ALHL were recruited between January 2018 and December 2019 and randomized into two groups: a steroid-with-diuretic (isosorbide) group and a steroid-only group. The steroid-with-diuretic group received oral methylprednisolone for 10 days and isosorbide for 14 days, while the steroid-only group received methylprednisolone for 10 days. Hearing outcomes were measured using pure-tone audiometry at 8 weeks posttreatment. The outcomes were the absolute hearing gain at low frequencies (125, 250, and 500 Hz) and the recovery rate, which was classified into complete, partial, unchanged, progressive, and fluctuating.
Results
Of 34 patients, 30 (15 in each group) were analyzed. No significant differences were observed in baseline characteristics between the groups. The steroid-with-diuretic group showed higher absolute hearing gains at all three low frequencies than the steroid-only group, but the differences were not statistically significant complete recovery was observed in 13 patients in each group, with partial recovery in two patients in the steroid-with-diuretic group and unchanged outcomes in two patients in the steroid-only group. No patient exhibited disease progression.
Conclusions
Although combined steroid and diuretic therapy yielded better hearing outcomes than steroid-only therapy, the differences were not statistically significant. Further studies with larger sample sizes and extended follow-up periods are necessary to confirm these findings.

Does dimenhydrinate delay recovery of vestibular ocular reflex in acute unilateral vestibulopathy? A retrospective comparative study: Minah Shin, Chae-Young Kim, Ji Eun Choi, Jae Yun Jung, Min Young Lee; Res Vestib Sci. 2024;23(3):89-94. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.006

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Abstract PDF: Objectives
Acute unilateral vestibulopathy (UVP), also known as vestibular neuritis, is the third most common peripheral vestibulopathy. The acute autonomic symptoms of UVP can be controlled by the H1-receptor antagonist dimenhydrinate. Despite concerns about prolonged recovery from suppressed vestibular compensation when using dimenhydrinate, research is limited. Thus, we investigated the effect of dimenhydrinate on the recovery of UVP patients.
Methods
We retrospectively analyzed patients who were diagnosed with UVP from April 2018 to April 2022. The patients were divided into those who were prescribed dimenhydrinate during admission and those who were not. Recovery from UVP was defined subjectively and objectively. Subjective recovery (SR) had occurred in a patient whose dizziness clearly subsided. Objective recovery (OR) was used when the video head-impulse test (VHIT) or rotary chair test (RCT) no longer indicated vestibular dysfunction.
Results
Dimenhydrinate was prescribed to 15 patients (19.0%) during admission. The dimenhydrinate group had smaller proportions of SR and OR at 3 months after diagnosis of UVP. In terms of VHIT, the non-dimenhydrinate group had a greater increase in gain for the 3 months than the dimenhydrinate group in the semicircular canals when measured by the VHIT. The difference in gain between the two groups was significant at 0.16 Hz during follow-up RCT.
Conclusion
These results suggest that dimenhydrinate should be carefully used in UVP patients as it may have a negative effect on vestibular compensation.

Effect of early high-dose steroid treatment in patients with acute vestibular neuritis: a retrospective case-control study: Jung-Yup Lee, Hyun-Seok Kang, Sang-Hyun Kim, Min-Beom Kim; Res Vestib Sci. 2024;23(2):53-60. Published online June 14, 2024; DOI: https://doi.org/10.21790/rvs.2024.007

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Abstract PDF: Objectives
This study is performed to evaluate the effect of early steroid treatment within 24 hours of onset in acute vestibular neuritis (AVN).
Methods
We performed a retrospective case-control study with 46 patients with AVN. Video head impulse test paradigm (HIMP) and suppression HIMP were performed, and dizziness handicap index (DHI) was determined at initial; all tests were repeated at 1 month. Patients were divided into two groups depending on whether they were treated with steroids (group S, n=21) or not (group n-S, n=25).
Results
There was no significant difference in age, sex, and side between the two groups. In HIMP, group S showed a significantly lower occurrence of overt corrective saccade (CS) (p=0.034) and lower peak velocity of overt CS (p=0.020) than group n-S at 1 month. In addition, the DHI score at 1 month was significantly lower in group S than in group n-S (p=0.040). In correlation analysis between subjective symptom and objective parameters, the DHI score showed a significant correlation with the occurrence of overt CS (p=0.028) and PR score (p=0.006) at 1 month.
Conclusions
Early steroid treatment in AVN would be helpful for relieving symptoms and the improvement of vestibular ocular reflex function in the recovery phase.

Serum otolin-1 level is specific to benign paroxysmal positional vertigo: Hoon Kim, Eun Ji Kim, Eunjin Kwon, Seong-Hae Jeong; Res Vestib Sci. 2024;23(2):46-52. Published online June 14, 2024; DOI: https://doi.org/10.21790/rvs.2024.008

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Abstract PDF: Objectives
When we see patients with a history of positional vertigo (PV), many patients are diagnosed with benign paroxysmal PV (BPPV) by performing a typical history and nystagmus during a positioning maneuver. Recent studies reported that Otolin-1 can be detected in serum and that its levels significantly increase with age and BPPV. Herein, we tried to study the relationship between serum otolin-1 level and the other clinical aspects in patients with PV.
Methods
We measured the serum levels of otolin-1 in 117 BPPV patients (82 females; age range, 43–92 years; mean age±standard deviation [SD], 68.5±10.5 years), referred to as the BPPV group; and nine patients (seven females; age range, 61–79 years; mean age±SD, 66.9±5.9 years) with PV not compatible with BPPV, referred to as another PV group. All the BPPV patients were treated with an appropriate canal repositioning maneuver followed by blood sampling within 1 week.
Results
The serum levels of otolin-1 were higher in the BPPV group than in another PV group (mean±SD, 350.1±319.1 pg/mL vs. 183.6±134.1 pg/mL, respectively; p=0.037). However, there were no differences in both laboratory findings (serum vitamin D, C-telopeptide of type collagen, and bone mineral density) and clinical findings (age, sex, vertigo duration, ear disease, ear symptom, migraine, motion sickness, trauma, and previous BPPV) between these two groups.
Conclusions
Serum otolin-1 level could help predict the current existence of BPPV in patients with PV. However, further validation studies are needed.

Prevalence and preferred medication for vestibular migraine in Menière’s disease: a multicenter retrospective cohort study in Korea: Dong-Han Lee, Hong Ju Park, Kyu-Sung Kim, Hyun Ji Kim, Jae-Yong Byun, Min-Beom Kim, Minbum Kim, Myung-Whan Suh, Jae-Hyun Seo, Jong Dae Lee, Eun-Ju Jeon, Myung Hoon Yoo, Seok Min Hong, Sung-Kwang Hong, Hyo-Jeong Lee, Jung Woo Lee, Se-Joon Oh, Hyun Ah Kim, Hyung Lee, Eek-Sung Lee, Eun-Jin Kwon, Seong-Hae Jeong, Jeong-Yoon Choi, Chang-Hee Kim; Res Vestib Sci. 2024;23(2):37-45. Published online June 14, 2024; DOI: https://doi.org/10.21790/rvs.2024.005

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Abstract PDF Supplementary Material: Objectives
The aim of this study is to categorize headaches associated with definite Menière’s disease (MD) according to diagnostic criteria, to determine their prevalence, and to investigate the preferred medication across participating centers.
Methods
Patients diagnosed with definite MD at 17 university hospitals in otolaryngology or neurology departments in Korea between January 1, 2021 to December 31, 2021 were retrospectively included. Data on the presence of accompanying vestibular migraine (VM), migraine or non-migraine headaches, and clinical information were collected. A survey was conducted to assess preferences for treatment drugs for vertigo and headache control in MD patients with headache.
Results
A total of 435 definite MD patients were included, with a mean age of 57.0±14.9 years. Among them, 135 (31.0%) had accompanying headaches, of whom 48 (11.0% of all definite MD patients) could be diagnosed with VM. The prevalence of comorbid VM (definite and probable) was significantly higher in females (41 of 288, 14.2%) than in males (7 of 147, 4.8%) (p<0.05). There was no significant difference in the prevalence of comorbid VM between unilateral and bilateral MD patients (10.8% and 13.6%, respectively) (p > 0.05). Benzodiazepines, antihistamines, and antiemetics were mainly preferred for acute vertigo control, while nonsteroidal anti-inflammatory drugs, acetaminophen, and triptans were preferred for acute headache control, and topiramate, propranolol, and calcium channel blockers were mainly preferred for headache prevention.
Conclusions
VM is not uncommon in patients with definite MD in Korea. Further research is needed to understand the differences in headache prevalence and preferred medications across different centers.

The clinical significance of arterial stiffness in the differential diagnosis of vertigo: Bang-Hoon Cho, Jae-Myung Kim, Young-In Kim, Seung-Han Lee; Res Vestib Sci. 2024;23(1):16-23. Published online March 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.003

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Abstract PDF Supplementary Material: Objectives
Pulse wave velocity (PWV) is a known indicator of arterial stiffness reflecting vascular damage. However, there are few reports of the relationship between PWV and dizziness/vertigo of a vascular origin. We investigated whether the PWV value could be useful as an ancillary measurement for identifying the etiology of dizziness/vertigo.
Methods
We enrolled dizzy patients from March 2016 to December 2018. The patients with posterior circulation stroke presenting with dizziness/vertigo were categorized as having central vertigo. The patients with vertigo due to benign paroxysmal positional vertigo, Ménière disease, or acute unilateral vestibulopathy were categorized as having peripheral vertigo. The PWV value, ankle-brachial index (ABI), and traditional vascular risk factors were collected.
Results
We consecutively enrolled a total of 93 participants. The PWV values were higher in the central vertigo group (p<0.001), but ABI did not differ between the groups. Among the vascular risk factors, the number of patients with diabetes mellitus, dyslipidemia, and male patients was significantly higher in the central vertigo group. The brachial-ankle PWV (baPWV) values were higher in the central vertigo group, even after adjusting for confounding factors (p<0.01). The receiver operating characteristic curve showed that the sensitivity was 74% and specificity was 81% when the mean baPWV value was 14.78 m/sec.
Conclusions
Increased baPWV values were observed in patients with dizziness/vertigo due to stroke. Measurement of the baPWV value could be an ancillary test for evaluating the cause of dizziness/vertigo, even though more convincing evidence is still required.

Comparison of vestibular evoked myogenic potentials between low and high tone idiopathic sudden sensorineural hearing loss: Sang-Wook Park, Sang Yun Lee, Somi Ryu, Jung Woo Lee, Chae Dong Yim, Dong Gu Hur, Seong-Ki Ahn; Res Vestib Sci. 2024;23(1):11-15. Published online March 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.001

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Abstract PDF: Objectives
Vestibular evoked myogenic potentials (VEMP) have been reported to be useful in evaluating not only vestibular function but also the prognosis of idiopathic sudden sensorineural hearing loss (ISSNHL) patients. Even though low frequency, high frequency, and all frequency-involved ISSNHL groups tend to show varied clinical characteristics, there is a lack of data using VEMP results to analyze these subgroups. We investigated if the VEMP test is a valuable tool to predict recovery from hearing loss in association with different frequencies.
Methods
A total of 26 ISSNHL patients were divided into three different groups impaired with low tone (ascending type), high tone (descending type), and all tones (flat type) based on the initial audiograms. Each group included five, 10, and 11 patents, respectively, and their VEMP results were compared between the three subgroups.
Results
Abnormal VEMP results were found in five of the total 26 ISSNHL patients (19.2%). Two (40.0%), one (10.0%), and two (18.1%) patients of low tone, high tone, and all tone hearing loss groups, respectively, showed abnormal VEMP results. However, there was no statistically significant difference between the three groups.
Conclusions
Even though VEMP is known as a valuable tool for predicting the prognosis of ISSNHL patients, it does not seem to reflect frequency-sensitive aspects of ISSNHL.

Unilateral Vestibulopathy Mimicking Inner Ear Ischemia Modeling Using Photothrombosis and Behavioral Assessment Using EthoVision: Min Seok Song, Min Young Lee, Ji Eun Choi, So-Young Chang, Jae-Hun Lee, John Patrick Cuenca, Nathaniel T. Carpena, Jae Yun Jung; Res Vestib Sci. 2023;22(4):112-119. Published online December 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.4.112

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Abstract PDF: Objectives
Inner ear ischemic animal models using photochemical reactions have been devised in various ways. Localized vascular ischemia occurs with 532-nm laser irradiation after systemic rose bengal injection, a known photothrombotic mechanism. The aim of this study is to evaluate a photothrombosis-induced vestibulopathy mimicking behavioral changes in the inner ear ischemia model.
Methods
Seven-week-old male Spraque-Dawley rats were used. Animals were divided into three groups: control group (n=6), sham laser group (n=9), and laser group (n=9). To induce the photothrombosis, animals were injected with rose bengal into the femoral vein and then were irradiated with a 532-nm laser (175 mW for 900 seconds) via transtympanic membrane. To investigate the vestibulopathy after photothrombosis, the behavior tests (tail lift reflex test, air righting reflex test, rotarod test) were performed on the 1st, 3rd, and 7th days after surgery. Additionally, an open field test was conducted and analyzed using EthoVision XT (Noldus).
Results
The laser group exhibited significant behavioral change to mimic vestibulopathy in all assessments. Inducing photothrombosis with rose bengal caused severe gait instability, which precluded rotarod testing. In the tail lift reflex test, the laser group displayed vestibular dysfunction with a lower angle formation compared to the control rats. During the open field test, the laser group exhibited reduced mobility, a condition that persisted in the laser groups for 7 days.
Conclusions
Noninvasive laser irradiation using rose bengal and a 532-nm laser induces photothrombosis in the inner ear of animals, leading to the development of vestibulopathy mimicking imbalanced behavior.

Efficacy of the Fixation Index of Bithermal Caloric Test for Differentiating Brain Lesions in Vestibular Disoder: Young Jae Lee, Wonyong Baek, Sung-Il Cho, Gi-Sung Nam; Res Vestib Sci. 2023;22(4):106-111. Published online December 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.4.106

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Abstract PDF: Objectives
This study was performed to investigate the efficacy of the fixation index (FI) of the bithermal caloric test for differentiating brain lesions in vestibular disorder.
Methods
We reviewed the medical records of 286 consecutive dizzy patients who underwent brain magnetic resonance imaging (MRI) and the bithermal caloric test at department of otorhinolarnygology. Central vestibulopathy (CVP) was defined as when corresponding lesion was identified on brain MRI, otherwise peripheral vestibulopathy (PVP) was defined. The FI was defined as the mean slow phase velocity (SPV) with fixation divided by the mean SPV without fixation, and failure was indicated when the FI exceeded 70%.
Results
The CVP confirmed by brain MRI and PVP were 16.8% and 83.2%, respectively. The most common CVPs were cerebellopontine angle tumor (n=19, 39.6%) and chronic cerebellar infarction (n=18, 37.5%). There were 23 cases of CVP (47.9%) and 47 cases of PVP (19.7%) with abnormal number of FI in at least two of the four caloric irrigations. The FI score of right cool (RC), left cool (LC), and right warm (RW) were also increased significantly in patients with CVP (p=0.031 at RCFI, p=0.014 at LCFI, p=0.047 at RWFI, and p=0.057 at LWFI; Mann-Whitney U-test).
Conclusions
If two or more abnormal FIs are detected during bithermal caloric testing, there is a high likelihood of CVP. Consequently, additional brain MRI may be necessary for further evaluation.

Clinical Outcomes of Endolymphatic Sac Decompression Surgery in Menière’s Disease: Hee Won Seo, Young Sang Cho, Won-Ho Chung; Res Vestib Sci. 2023;22(4):97-105. Published online December 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.4.97

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Abstract PDF: Objectives
Endolymphatic sac decompression surgery (ESDS) is one of the surgical methods for intractable Menière’s disease (MD), and it is known as a relatively safe treatment that does not cause hearing loss. However, the effectiveness and the degree of vertigo control rate of ESDS are still controversial. In this study, we aimed to evaluate the clinical outcomes of ESDS in intractable MD.
Methods
We retrospectively reviewed 33 patients who underwent ESDS for intractable MD from January 2002 to March 2022. Clinical characteristics of patients, pure tone threshold, medical treatment method, and number of vertigo attacks before and after surgery were assessed. The improvement of hearing and vertigo was evaluated according to the 1995 American Academy of Otolaryngology-Head and Neck Surgery criteria.
Results
Of the 33 patients, the average follow-up period was 21.2 months, with immediate follow-up within 2 months (28 patients), short term between 2 and 6 months (27 patients), and long term at 12 months or later (29 patients). In the immediate hearing threshold, both air conduction and bone conduction showed slight deterioration, but there was no significant change in the long-term hearing threshold. At long-term follow-up, 12 patients (41.4%) were able to live without medication, and 18 patients (62.1%) showed improvement in their vertigo symptoms. In addition, patients who showed improvement in hearing also showed improvement in vertigo at the same time.
Conclusions
ESDS in intractable MD is a relatively safe and effective treatment method for reducing vertigo attack without worsening hearing threshold.

Quantifying the Prevalence of Acute Vestibular Neuritis through Big Data Analysis: Chul Young Yoon, Seulgi Hong, Ji-Yun Park, Young Joon Seo; Res Vestib Sci. 2023;22(3):68-76. Published online September 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.3.68

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Abstract PDF Supplementary Material: Objectives
Big data analytics in healthcare research have gained momentum, offering unprecedented opportunities to investigate complex medical conditions like acute vestibular neuritis (AVN). However, an inappropriate definition can introduce bias and inaccuracies into prevalence estimation, making the results unreliable and hindering cross-study comparisons. The Health Insurance data in South Korea will be used to create a robust operational definition for AVN.
Methods
The study utilized the National Patients Sample dataset from the Health Insurance Review and Assessment Service (HIRA) of the Republic of Korea. The operational definition of AVN was defined using the HIRA data, which includes specific codes for diagnosis, testing, and medications. The revised categorization scheme for AVN was presented as case 1 through case 5, with criteria for each category.
Results
The optimal conditions are deemed to be those that encompass the outcomes of both case 5 and case 1-1, encompassing all conditions. The study also provided prevalence estimates for subgroups based on demographic factors (age, sex), and found a consistent pattern throughout all years, sex, and age.
Conclusions
The study analyzed the prevalence of AVN in case 1 and case 5, which were similar to the reference prevalence of 3.5 per 100,000 people reported in other countries. The study’s results are encouraging for several reasons, including the validity of the operational definitions used, and the agreement between the study’s prevalence estimates and the reference prevalence. The operational definition in statistics, in the context of big data, serves as a precise and standardized criterion.

Re-fixation Saccade at Video-Head Impulse Test in Patients with Sudden Sensorineural Hearing Loss: Dong Hyuk Jang, Sun Seong Kang, Hyun Joon Shim, Yong-Hwi An; Res Vestib Sci. 2023;22(2):46-51. Published online June 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.2.46

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Abstract PDF: Objectives
This study was performed to evaluate characteristics and their prognostic value of video-head impulse test (vHIT) in sudden sensorineural hearing loss (SSNHL) with vertigo.
Methods
Of the 612 patients with a diagnosis of SSNHL from 2010 to 2018, 110 patients (18.0%) with vertigo and 39 patients (6.4%) with vHIT results were recruited. The patients were evaluated for their pure-tone hearing average (at initial, 1-month, and 6-month visit), the presence of re-fixation saccade and gains at vHIT, the canal paresis (CP) at ccaloric test.
Results
Patients with saccade (+) showed higher pure-tone averages than those with saccade (‒) on initial and follow-up audiograms. The improvement in pure-tone averages was less in the saccade (+) group than in the saccade (‒) group. There was no significant difference of hearing recovery between SSNHL patients with normal gain and those with decreased gain. There was no difference of hearing improvement between CP (+) and CP (‒) groups according to the presence of re-fixation saccade.
Conclusions
Concurrent re-fixation saccade at vHIT is a negative prognostic factor of hearing function in SSNHL. Re-fixation saccade in SSNHL may suggest widespread damages to both the cochlea and the vestibule, leading to the poor prognosis.

A Comparative Analysis of the Vestibulocochlear Function in Patients with Isolated Semicircular Canal Hypofunction Using a Video Head Impulse Test: Yu Jung Park, Min Young Lee, Ji Eun Choi, Jae Yun Jung, Jung Hwa Bahng; Res Vestib Sci. 2023;22(2):34-45. Published online June 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.2.34

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Abstract PDF: Objectives
The objective of this study was to analyze vestibulocochlear function results in patients identified with isolated semicircular canal (SCC) hypofunction using the video head impulse test (vHIT).
Methods
A retrospective review was conducted on the clinical records of 123 patients diagnosed with isolated SCC hypofunction based on vHIT results. Among these patients, 72 had isolated posterior SCC (PSCC) hypofunction, 25 had isolated lateral SCC (LSCC) hypofunction, and 26 had isolated anterior SCC (ASCC) hypofunction. Descriptive analyses were performed on various vestibulocochlear tests including pure tone audiometry, sinusoidal harmonic acceleration (SHA), spontaneous nystagmus (SN), head-shaking nystagmus (HSN), caloric testing, and cervical vestibular evoked myogenic potential, with results analyzed separately for each SCC hypofunction group.
Results
The study found that 66.0% of the evaluated patients exhibited abnormal results in at least one vestibulocochlear function test. PSCC hypofunction patients showed a significantly higher incidence of hearing loss compared to ASCC and LSCC hypofunction patients. LSCC hypofunction patients exhibited higher rates of corrective saccade, phase asymmetry of SHA, and SN abnormalities compared to other SCC hypofunction patients. Additionally, the rates of corrective saccade and phase asymmetry of SHA were also higher in LSCC hypofunction patients. ASCC hypofunction patients demonstrated significantly higher rates of normal corrective saccade, phase lead of SHA, and SN.
Conclusions
The analysis of this study suggests that even in cases where vHIT indicates isolated SCC hypofunction, additional vestibulocochlear function tests should be conducted to identify any associated vestibulocochlear dysfunctions. This highlights the importance of comprehensive evaluation to accurately diagnose and manage patients with SCC hypofunction.

Clinical Characteristics of Benign Paroxysmal Positional Vertigo Positive on Bilateral Dix-Hallpike Test: Youngrok Jo, Gun Min Lee, Youn Jin Cho, Mi Joo Kim, Minbum Kim; Res Vestib Sci. 2023;22(1):14-18. Published online March 13, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.1.14

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Abstract PDF: Objectives
The purpose of this study is to investigate the clinical characteristics of benign paroxysmal positional vertigo (BPPV) which showed torsional nystagmus on bilateral Dix-Hallpike test, and to analyze the clinical features of pseudo-bilateral BPPV.
Methods
This study is a retrospective chart review of a total of 341 patients diagnosed with BPPV of posterior canal (PC-BPPV). Among them, patients who showed torsional nystagmus on bilateral Dix-Hallpike test were defined as “bilateral DixHallpike positive patients,” who were classified into true- and pseudo-bilateral PC-BPPV group through analysis of nystagmus direction. And pseudo-bilateral PC-BPPV were categorized into two subtypes according to their pathomechanisms. Clinical characteristics including sex, age, underlying vestibular disorders, recurrence and the number of Epley maneuvers were analyzed. Student t-test and Mann-Whitney U-test were used for statistical analysis.
Results
Among 341 patients, 27 patients (7.9%) were “bilateral Dix-Hallpike positive patients”. They received more Epley maneuvers than the group of unilateral PC-BPPV until the resolution of nystagmus (2.3 vs. 1.4, p＜0.001). Fifteen patients out of 27 were diagnosed with pseudo-bilateral PC-BPPV, who were classified into two subtypes according to their pathomechanisms. The number of Epley maneuvers was not different between true- and pseudo-bilateral PC-BPPV.
Conclusions
Patients with pseudo-bilateral PC-BPPV were common among “bilateral Dix-Hallpike positive patients.” For their better treatment, understanding of possible pathophysiology, accurate Dix-Hallpike test and detailed analysis of nystagmus direction are necessary.

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