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Concept: Benign paroxysmal positional vertigo

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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.

Concepts: Medical terms, Semicircular canal, Prognosis, Ear, Canal, Pathologic nystagmus, Benign paroxysmal positional vertigo, Horizontal semicircular canal

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We report on a 61-year-old woman with cupulolithiasis of the right horizontal semicircular canal, which is usually difficult to treat. The patient reported that several years ago, similar symptoms relieved completely after having performed several somersaults together with her granddaughter. This time, repetitive somersaults were again effective to treat her benign paroxysmal positional vertigo. Acceleration during a somersault may induce an intracanalicular force strong enough to detach otoconia debris from the cupula. Rolling may then promote their reentrance into the utricle. This case suggests that repetitive somersaults may be an alternative treatment of cupulolithiasis of the horizontal semicircular canal.

Concepts: Report, Semicircular canal, Alternative medicine, Classical mechanics, Ear, Benign paroxysmal positional vertigo, Treats, Somersault

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PURPOSE OF REVIEW: This review examines the research from 2011 through 2012 on treatment efficacy in two common vestibular disorders - vestibular hypofunction and benign paroxysmal positional vertigo (BPPV). RECENT FINDINGS: Significant numbers of randomized controlled trials now support the use of specific exercises for the treatment of patients with unilateral peripheral vestibular hypofunction. We do not know if some treatment approaches are more effective than others. There is preliminary evidence that head movement may be the component critical to recovered function and decreased symptoms. Some patient characteristics and initial assessment results appear to predict treatment outcome but the evidence is incomplete. Treatment of posterior canal BPPV canalithiasis is well established. New evidence supports certain treatments for horizontal canal BPPV. SUMMARY: Treatments for unilateral vestibular hypofunction and for posterior canal BPPV are effective; however, there are many as yet unanswered questions such as why some patients with vestibular hypofunction do not improve with a course of vestibular exercises. We also do not know what would be the best treatment for anterior canal BPPV or for multiple-canal involvement BPPV.

Concepts: Clinical trial, Critical thinking, Patient, Randomized controlled trial, Effectiveness, Efficacy, Pathologic nystagmus, Benign paroxysmal positional vertigo

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INTRODUCTION: Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder. However, BPPV in children has been studied less extensively than in the adult population. This is because the observation of benign paroxysmal positional nystagmus (BPPN) in children is technically very difficult and BPPV is rare in children. In this study, we present the only two cases of BPPV in children in which we successfully recorded and analyzed the BPPN. METHODS: One case was an 11-year-old boy and the other was a 3-year-old girl. We analyzed their BPPN three-dimensionally. RESULTS: Apogeotropic positional nystagmus was observed in the first case. We analyzed it to verify the presence of cupulolithiasis in the horizontal semicircular canal (HSCC). Geotropic positional nystagmus was observed in the second case, and the analyzed data indicated the presence of canalolithiasis in HSCC. Over the last decade, we have examined 3341 patients complaining of vertigo or dizziness. Among them, there were 63 children with the same complaint, so that the proportion of cases of BPPV in children was only 3% (2/63). DISCUSSION: Among patients complaining of vertigo or dizziness, children with BPPV are rare (3%). However, we have recorded their BPPN to confirm that BPPV does occur in children and that their characteristics of positional nystagmus are generally identical to those in adults. We emphasize that this is the first report of a child as young as 3 years old being diagnosed with BPPV.

Concepts: Scientific method, Observation, Semicircular canal, Ear, Case, Pathologic nystagmus, Complaint, Benign paroxysmal positional vertigo

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To investigate whether reported vertigo during the Epley maneuver predicts therapeutic success in patients with benign paroxysmal positioning vertigo of the posterior semicircular canal (pc-BPPV). Fifty consecutive adult patients with pc-BPPV, based on a positive Dix-Hallpike test (DHT), were treated with the Epley maneuver and retested after 2 days. Patients were asked to report the presence of vertigo upon assuming each of the four positions of the maneuver. Thirty seven patients (74 %) were treated successfully in one session. Twenty out of 23 patients who reported vertigo at turning the head to the opposite side (2nd position) had a negative DHT on follow-up. These patients had a higher chance of a successful outcome compared to patients who did not report vertigo in the 2nd position (Odds ratio 5.3, 95 % CI: 1.3-22.2, p = 0.022). Report of vertigo at the other positions was not associated with the outcome. Report of vertigo at the second position of a single modified Epley maneuver is associated with therapeutic success.

Concepts: Report, Semicircular canal, Success, Odds, Benign paroxysmal positional vertigo, Epley maneuver, Positioning, Posterior semicircular canal

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OBJECTIVES/HYPOTHESIS: Benign paroxysmal positional vertigo (BPPV) frequently occurs in females over 50 years old, suggesting that a postmenopausal decrease in estrogen secretion might be involved in its onset. An estrogen deficiency is generally known to cause osteoporosis through a reduction in bone mass. This study was designed to investigate a clinical association between idiopathic BPPV and osteoporosis. STUDY DESIGN: Case-control study. METHODS: We measured the bone mineral density (BMD) at the lumbar vertebrae in 61 patients with idiopathic BPPV who were postmenopausal women over 50 years old using dual-energy x-ray absorptiometry. After being treated with the canalith repositioning maneuver, the patients were followed up for at least 1 year. RESULTS: Our results showed that the incidence of osteoporosis in patients with BPPV was 26.2%, which was similar to those observed in epidemiological surveys conducted in Japan. However, we found that in BPPV patients with osteoporosis, the incidence of recurrence was 56.3%, which was significantly higher than that observed in patients with normal bone mineral density (16.1%). Furthermore, the frequency of BPPV recurrence increased as BMD decreased. CONCLUSIONS: These results suggest that osteoporosis is a risk factor for BPPV recurrence. The prognosis of BPPV might be clinically predicted by BMD reduction. LEVEL OF EVIDENCE: 3b Laryngoscope, 2013.

Concepts: Osteoporosis, Bone, Epidemiology, Bone density, Skeletal system, Dual energy X-ray absorptiometry, Osteopenia, Benign paroxysmal positional vertigo

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There are reports of an association between benign paroxysmal positional vertigo and hyperuricemia. We sought to determine the risk of vertigo among patients with gout compared with the general population, using a nationwide Taiwanese population-based claims database. Our study cohort consisted of patients with a diagnosis of gout disorders in 2004 (N=18773). Four age- and gender-matched controls for every patient in the study cohort were selected using random sampling as the comparison cohort (N=75092). All subjects were followed from the date of cohort entry until they developed vertigo or to the end of 2006. Cox proportional hazard regressions were performed to evaluate the 3-year vertigo-free survival rates. Of the total sample, 2563 (incidence, 10.09 per 1000 person-years) had vertigo during the 3-year follow-up period: 570 (incidence, 11.78 per 1000 person-years) from the study cohort and 1993 (incidence, 9.69 per 1000 person-years) from the comparison cohort. The adjusted hazard ratios (HR) of peripheral and central vertigo in patients with gout compared with controls during the 2-3-year follow-up were 1.17 (95% confidence interval [CI]=1.05-1.29, p=0.003) and 1.08 (95% CI=0.86-1.36, p=0.53), respectively. This is the first population-based study performed to suggest that patients with gout may have an increased risk of peripheral vertigo but not central vertigo. Benign paroxysmal positional vertigo may be the reason for the observed association; however, future studies are required to further ascertain the relationship between gout and the various causes of peripheral vertigo.

Concepts: Sample, Cohort study, Sample size, Sampling, Risk, Confidence interval, Benign paroxysmal positional vertigo, Roman numerals

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OBJECTIVE: The relatively low success rate of the treatment maneuver for horizontal semicircular canal (HSC) benign paroxysmal positional vertigo (BPPV) may be caused by the difficulty determining the affected side. We developed a 180-degree supine roll test (SRT) by modifying the 90-degree SRT to increase diagnostic accuracy and evaluated its significance. STUDY DESIGN: A prospective study. SETTING: Tertiary referral center. PATIENTS: A total of 122 patients with HSC-BPPV performed both the 90- and 180-degree SRTs. INTERVENTIONS: The affected side was determined by the 90- and 180-degree SRTs. The bow and lean (BL) test was also performed in cases with ambiguous or opposite results on both SRTs. MAIN OUTCOME MEASURE: A comparison of the difference in slow phase velocity (SPV) of nystagmus among the 90- and 180-degree SRTs and BL test. RESULTS: The maximum SPV of nystagmus during the 180-degree SRT was significantly greater than that during the 90-degree SRT. The SPV difference was less in the 180-degree SRT than that in the 90-degree SRT. Although the 180-degree SRT showed fewer meaningful results (n = 65) than the 90-degree SRT (n = 71), the affected side was determined by the 180-degree SRT in 15 cases with ambiguous results on the 90-degree SRT. Among 10 cases showing opposite results, 7 were identified by the BL test. Five (71.4%) of 7 cases had consistent affected sides with the 180-degree SRT. CONCLUSION: The 180-degree SRT can be an additional method when it is difficult to determine the affected side from the 90-degree SRT.

Concepts: Measurement, Semicircular canal, Arithmetic, Ear, Determinacy, Pathologic nystagmus, Benign paroxysmal positional vertigo, Horizontal semicircular canal

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Abstract Conclusion: In the present study, about one-third of patients with Meniere’s disease developed benign paroxysmal positional vertigo (BPPV)-like attacks. Additionally, more than one-third of all vertigo attacks were BPPV-like attacks. Thus, vertigo attacks in patients with Meniere’s disease must be carefully treated because the therapy for such vertigo attacks is totally different from the therapy for BPPV. Objective: Physicians sometimes encounter patients with previously diagnosed Meniere’s disease who develop BPPV attacks during the course of clinical follow-up. In this study, we explored the frequency with which BPPV was involved in all vertiginous episodes among patients with Meniere’s disease. Methods: This retrospective study involved 296 patients with Meniere’s disease who visited Kyoto University Hospital. The diagnosis of Meniere’s disease was based on the guidelines for the diagnosis of Meniere’s disease proposed by the Committee on Hearing and Equilibrium. We judged the cause of vertigo as one of the following five types: (1) definite Meniere’s disease attack, (2) suspicious Meniere’s disease attack, (3) definite BPPV attack, (4) suspicious BPPV attack, or (5) unknown. Results: In all, 96 patients (32.8%) developed BPPV-like attacks, and 187 vertiginous episodes (37.9%) were caused by BPPV. The lateral semicircular canal was the most frequently involved canal.

Concepts: Hospital, Physician, Semicircular canal, Ear, Ménière's disease, Pathologic nystagmus, Benign paroxysmal positional vertigo, Diseases of inner ear

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Objectives: Using American bullfrog models under normal conditions and under vestibular dysfunction, we investigated whether mechanical vibration applied to the ear could induce otoconial dislodgement. Methods: Vibration was applied to the labyrinth of the bullfrog using a surgical drill. The time required for the otoconia to dislodge from the utricular macula was measured. Vestibular dysfunction models were created and the dislodgement time was compared with the normal models. The morphology of the utricular macula was also investigated. Results: In the normal models, the average time for otoconial dislodgement to occur was 7 min and 36 s; in the vestibular dysfunction models, it was 2 min and 11 s. Pathological investigation revealed that the sensory hairs of the utricle were reduced in number and that the sensory cells became atrophic in the vestibular dysfunction models. Conclusion: The otoconia of the utricle were dislodged into the semicircular canal after applying vibration. The time to dislodgement was significantly shorter in the vestibular dysfunction models than in the normal models; the utricular macula sustained significant morphological damage.

Concepts: Vestibular system, Ear, Inner ear, Mode shape, Benign paroxysmal positional vertigo, Otolith, Utricle