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.
Objectives Pathophysiology of vestibular migraine (VM) is still controversial. Vertigo may act as a trigger for migraine or there might other mechanisms which cause migraine and dizziness. VM patients have headaches and dizziness simultaneously or sequentially. Therefore, we hypothesized that the sequence of symptoms might suggest different mechanisms and compared the results of vestibular function tests (VFTs) according to chronological order of headache and vertigo.
Methods Forty-two patients with VM were included. They were divided into three subgroups according to the chronological orders of headache and vertigo, and the results of VFTs and the symptomatic improvement were compared between each group.
Results Dizziness appeared first in 15 patients (35.7%), both symptoms appeared simultaneously in 20 patients (47.6%), and headaches appeared first in 7 (16.7%). There were no significant differences in symptom duration among the groups. Fourteen (33.3%) showed abnormal caloric results, 7 (16.7%) in head impulse test, 16 (38.1%, vestibular score) and 19 (45.2%, composite score) in sensory organizing test, and 13 (31.0%) in vestibular evoked myogenic potential test. Abnormal rate of the caloric test in the simultaneous group was significantly lower than those of the other two groups. Nineteen (45.2%) showed complete remission in 3 months after preventive medication with no significant difference between each group.
Conclusions VM patients whose vertigo occurred with headache simultaneously showed lower incidence of caloric abnormality, suggesting that they have abnormality in central vestibular system rather than peripheral vestibular organs.
Benign paroxysmal positional vertigo (BPPV) is the most common cause of recurrent vertigo that is characterized by sudden onset of vertigo elicited by positional change. American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and American Academy of Neurology provided clinical practice guideline for BPPV in 2008. Since then, Bárány Society has published BPPV diagnostic criteria in 2015, and AAO-HNS has revised BPPV clinical practice guideline in 2017 to publish update version. This article reviewed recent diagnostic criteria for BPPV included in the International Classification of Vestibular Disorders of Bárány Society and updated practice guideline in the BPPV diagnosis presented by AAO-HNS.
A 25-year-old woman presented with atypical dizziness with oscillopsia. The neuro-otological evaluations showed bilateral vestibulopathy with mild sensorineural hearing loss. Computed tomography and magnetic resonance imaging demonstrated bilateral isolated lateral canal dysplasia (LSCD) with normal cochlea. LSCD is relatively common inner ear malformation, but it is rarely found in bilateral vestibulopathy. In case of patients with bilateral vestibulopathy who cannot find the cause, should be considered conducting radiological examinations in mind of the inner ear anomalies.
Recently with the introduction of video head impulse test (vHIT), it can be easily performed quantitative and objective measurement of vestibulo-ocular reflex (VOR). vHIT has been used as a clinical vestibular function test that can individually evaluate the function of each semicircular canal. Loss of VOR gain and corrective catch-up saccades that occur during the vHIT usually indicate peripheral vestibular hypofunction, whereas in acute vestibular syndrome, normal vHIT should prompt a search for a central lesion. In this study, we will examine the principle of vHIT and its interpretation, and explain its clinical application
in peripheral and central vestibulopathy. In addition, we will compare the caloric test and the differences, and review the most recently introduced suppression head impulse paradigm test.
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Case history of a 67-year-old man diagnosed with posterior benign paroxysmal positional vertigo (BPPV) with extremely long latencies after holding the Dix-Hallpike position for five minutes. Additional vestibular assessment indicated partial unilateral hypofunction. The patient had a history compatible with classic BPPV. This patient, however, did not have any positional nystagmus after doing standard positional testing. With extremely prolonged Dix-Hallpike testing (five minutes), the patient experienced nausea and vertigo. Concomitantly classic peripheral nystagmus was observed. After a total of seventeen treatments in a reposition chair a total relief of symptoms was obtained. The extremely long latencies observed in this patient were ascribed to otoconial adherence and/or otoconial size. This type of BPPV has not previously been described.
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Horizontal canal benign paroxysmal positional vertigo (HC-BPPV) can be classified as either the geotropic or apogeotropic subtype by the pattern of nystagmus triggered by supine head roll test. Most studies have reported the geotropic subtype as a more common pathophysiology in HC-BPPV than the apogeotropic subtype. According to the BPPV clinical practice guideline provided by the American Academy of Otolaryngology-Head and Neck Surgery and American Academy of Neurology in 2008, variations of the roll maneuver (Lempert maneuver of barbecue roll maneuver) are the most widely published treatments for HC-BPPV. In addition, various treatment techniques including Gufoni maneuver, Vannuchi-Asprella liberatory maneuver and forced prolonged positioning have been applied for HC-BPPV. However, the guideline failed to provide specific treatment guidelines for HC-BPPV based on evidence-based researches since only Class IV data on HC-BPPV treatment were available at the point of 2008 when the BPPV clinical practice guideline was published. This review article focused on the evidences of the efficacy of various maneuvers in the treatment of HC-BPPV published after the BPPV clinical practice guidelines of 2008.
Benign paroxysmal positional vertigo (BPPV) is inner ear disorder caused by a displacement by otoconia from the utricle into semicircular canal (SCC). It is usually present as a definite vertigo spell induced by change in head position. Even though the posterior canal is by far most frequent, BPPV can involve any SCC. The diagnosis is confirmed by typical clinical presentation and positional tests. The aim of the review article was to provide a current opinion regarding vertical canal BPPV.
Superior semicircular canal dehiscence syndrome (SCDS) is characterized by cochleovestibular hyper-responsiveness symptoms including sound- and pressure- evoked vertigo and oscillopsia, autophony, hyperacusis and ear fullness. The typical audiometric feature of SCDS is known as conductive hearing loss at low frequency. A 43-year-old man presented with unilateral sudden deafness after several events of heading during soccer game. High-resolution temporal bone computed tomography revealed a dehiscence of superior canal encased by superior petrous sinus. We reviewed audio-vestibular findings in this patient and speculated potential pathogenic mechanisms of sudden deafness in SCDS with literature review.
Background and Objectives: The aim of this study is to evaluate the relationship between the recurrence and clinical features of posterior canal benign paroxysmal positional vertigo (p-BPPV). Materials and Methods: Eighty one consecutive patients with p-BPPV in 1 year period were selected and traced for 2 years by telephone interview and chart review. We reviewed the clinical chart to confirm the lesional side of semicircular canals when 13 patients of the recurrent groups had readmitted. We compared clinical characters between the recurrent group and the nonrecurrent group. Results: The recurrence rate after the successful treatment in the p-BPPV is 28% (23/81) patients. There was no difference in the age, sex, and days prior to visit between the recurrent group and the nonrecurrent group (72%, 58/81). The interval to recurrences were ranged from 8 days to 24 months. In the patients we could confirm the side of recurrences (13/23), there was a tendency of recurring on the same side in the early recurrences (within 14 days) (4/13). Conclusion: In considering the causes, the fact that early recurrences tend to be on the same side may be related to unilateral otolith dysfunction as the cause of recurrences in p-BPPV. But the late recurrence may be related to systemic condition because recurrent BPPV developed equally on both sides.
Background and Objectives: At the beginning of the Dix-Hallpike maneuver, one of the two functional pair planes of the vertical canals is presumed to lie in the sagittal plane. However, this presumption is not correct. This paper aims to describe this problem more clearly and speculate on clinical implications. Mathematical and theoretical reasoning will be discussed.
Materials and Methods: Two sets, each composed of three perpendicular planes, were modeled for simplified semicircular canals in the anatomical position with a 3D modeler. After a yaw rotation of 45°, the surface normal of the vertical canal plane is compared with that of the true sagittal plane.
Results: The angle between the two normals was approximately 21.1 degrees. The theoretical vertical canal plane did not lie in the sagittal plane at the beginning position of Dix-Hallpike maneuver.
Conclusions: More exact Dix-Hallpike maneuvers may require a roll tilting about 20° toward the affected side.
Key words: Benign paroxysmal positional vertigo, Dix-Hallpike maneuver, Semicircular canals