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Background and purpose Horizontal canal benign paroxysmal positional vertigo (BPPV) is the second most common variant of BPPV after posterior canal BPPV. Various liberatory maneuvers are recommended for the treatment of horizontal canal BPPV canalithiasis (hc-BPPV-ca). The aim of this study was to show how three-dimensional (3D) dynamic simulation models visualize the movement of the clot of otoconia within the canal for a better understanding of the theoretical efficacy. Methods Based on reconstructed magnetic resonance imaging and fluid dynamics, a 3D dynamic simulation model (as a function of time) was developed and applied. Thereby, six treatment maneuvers for hc-BPPV-ca were simulated: two types of the roll maneuver (the original 270 degrees and the modified 360 degrees) as well as two Gufoni and Zuma maneuvers (for geotropic and apogeotropic nystagmus). Results The simulations showed that the 360 degrees roll maneuver and Zuma maneuver are effective treatment options for hc-BPPV-ca for debris in all locations within the canal. However, the original 270 degrees roll maneuver will not be effective if the clot is in the ampullary arm of the horizontal canal. The Gufoni maneuver for geotropic hc-BPPV-ca is effective, whereas for apogeotropic hc-BPPV-ca there is a risk of treatment failure due to insufficient repositioning of the debris. Conclusions The 3D simulations for movement of the otoconia clots can be used to test the mechanism of action and the theoretical efficacy of existing maneuvers for the different BPPV variants. For hc-BPPV-ca, the modified 360 degrees roll maneuver and Zuma maneuver are theoretically efficient for all subtypes, whereas Gufoni maneuver is effective for geotropic nystagmus only.

The vertigo associated with horizontal canal benign paroxysmal positional vertigo (BPPV) is usually much more intense than that associated with posterior canal BPPV. In addition, horizontal canal B...

Objective To examine the treatment effects of repositioning maneuvers with the head turned 45° downwards (Gufoni maneuver) and 45° upwards (Appiani maneuver) in 25 patients with ageotropic horizontal semicircular canal (HSCC) benign paroxysmal positional vertigo (BPPV). Methods Patients were randomly assigned to the Gufoni or Appiani maneuvers, and their immediate and short‐term efficacy was investigated. Results The immediate treatment response was successful in four of 16 patients who were treated with the Appiani maneuver and were not successful in any of the nine patients treated with the Gufoni maneuver. The patients who showed spontaneous resolution during follow‐up outnumbered the patients who showed resolution of ageotropic HSCC BPPV immediately after the repositioning maneuvers. Conclusion This study showed a very low immediate resolution rate of ageotropic HSCC BPPV after the Gufoni maneuver; this may be attributed to the less effectiveness of the Gufoni maneuver against debris that often exists in the canal side of the cupula. Another interesting finding was that the rate of spontaneous resolution during the follow‐up period was higher than that of immediate resolution after the repositioning maneuvers, which may support the recently proposed hypothesis that ageotropic positional nystagmus can also be evoked by causes other than the otolithic attachment on the cupula, such as a slight change in the biochemical composition of the inner ear fluids. Level of Evidence 3.

Objective We aimed to describe the clinical features of the apogeotropic variant of horizontal canal benign paroxysmal positional vertigo (HC BPPV-AG) in a cluster of patients with restrictive neck movement disorders and a new therapeutic manoeuvre for its management. Methods In a retrospective review of cases from an ambulatory tertiary referral center, patients with HC BPPV-AG in combination with neck movement restriction that prevented any classical manual repositioning procedure or who were refractory to canalith repositioning manoeuvres, were treated with a new manoeuvre comprised of sequential square-wave pattern of head and body supine rotations while nystagmus was being monitored, until either an apogeotropic to geotropic conversion or resolution of the nystagmus was observed. Results Fifteen patients were studied. All but one [14/15 cases] showed a positive therapeutic response to the repositioning procedure in a single session. In two cases, a direct relief of vertigo and elimination of nystagmus was observed without an intermediate geotropic phase. Although in three patients the affected ear was not initially identified, it was ultimately identified and successfully treated by the square wave manoeuvre in all of them. Conclusions The square-wave manoeuvre is an alternative for HC BPPV-AG treatment in either cases with neck restriction, where the affected side is not well identified at the bedside or when other manoeuvres fail to resolve the HC BPPV-AG.

There have been no useful imaging methods to diagnose benign paroxysmal positional vertigo (BPPV), a common cause of vertigo, depending on the characteristic symptom.To visualize horizontal canal (HC) BPPV using 3DCT and assess its clinical usefulness.Ten BPPV patients were diagnosed with distinct BPPV, canalolithiasis, and cupulolithiasis of the HC (hc-BPPV, hc-BPPV-cu), which were definitely diagnosed on the basis of criteria of BPPV by the Barany Society and 10 healthy subjects without a history of dizziness were investigated using 3DCT with several different CT window values (CTWVs).The HCs of BPPV patients were clearly visualized and the luminal aspects showed differences among ears with cupulolithiasis, canalolithiasis and no symptoms healthy subjects.3DCT images visualized the characteristic changes of the HC of patients with BPPV compared to healthy subjects. The HC images were coincident with the clinical condition of cupulolithiasis and canalolithiasis. This imaging technique is clinically useful for diagnosing, treating and assessing the prognosis of HC BPPV.

Objectives Brandt-Daroff exercises (BDEs) are commonly used as an at-home treatment for posterior canalithiasis, but their efficacy in the treatment of benign paroxysmal positional vertigo (BPPV) of the horizontal canal (HC-BPPV) has not been previously studied. Using biomechanical model simulation, we investigated modifications that may optimize BDE use for HC-BPPV treatment. Materials and methods The BPPV Viewer, a three-dimensional model of the human labyrinth, was used to analyze BDE for HC-BPPV treatment. While moving the model through sequential BDE positions, the expected position of otoliths was demonstrated. Treatment steps were adjusted to maximize otolith movement around the canal circumference without compromising otolith repositioning into the semicircular duct's anterior arm. All adjustments were integrated into lateral modified BDEs (LMBDEs) presented here. Results By implementing several modifications, BDE can effectively treat HC-BPPV. Model simulation indicates tilting the head 20° upward in the lateral position, instead of 45° specified by the original technique, which significantly increases displacement of otoliths originating from the horizontal duct's anterior and intermediate segments. LMBDE can be performed as a direct two-step sequence without pausing in the upright position before switching sides. If the affected ear is known, positioning the head 45° below horizontal on the unaffected side as a third treatment step can promote actual canal evacuation. These treatment enhancements increase circumferential otolith movement around the canal and may promote horizontal canal evacuation. Conclusion LMBDEs are a modification of BDE that may increase their effectiveness for use in patients with HC-BPPV. This safe treatment adjunct between office visits may promote long-term symptom reduction.

This study aimed to determine the prevalence and mechanism of linear vertigo reported by the patients during the attacks of benign paroxysmal positional vertigo (BPPV). We prospectively evaluated the characteristics (rotational vs. linear) of positional vertigo in 70 patients with posterior and horizontal canal BPPV using a questionnaire allowing multiple choices. In patients with linear vertigo, we further assessed the directionality of linear vertigo. We adopted the velocity-storage model to explain the occurrence and direction of linear vertigo in these patients with BPPV. Patients reported only rotational vertigo in 46 (46/70, 65.7%), only linear vertigo in 10 (14.3%), and both rotational and linear vertigo in 14 (20%). The patients experienced fear from rotational vertigo in 54 (54/70, 77.1%) and from linear vertigo in 20 (20/70, 28.6%). The direction of linear vertigo was concordant with the direction of inertial acceleration predicted by the velocity-storage model. Patients with BPPV may experience linear as well as rotational vertigo during the attacks. This linear vertigo may be ascribed to centrally estimated inertial acceleration.

Objectives To compare the effect of a high-speed barbecue maneuver with the modified Lempert maneuver and sham in patients with benign paroxysmal positional vertigo (BPPV) of the horizontal canal. Methods Randomized sham-controlled, single blinded multicenter clinical trial in two university hospitals investigating consecutive patients with horizontal canal BPPV.Patients were randomly assigned to high-speed barbecue (HSB), modified Lempert maneuver (ML), or sham maneuver (SM). All treatments were performed in a biaxial rotational chair with weekly follow-up to a maximum of three treatment sessions. The final follow-up was 3 months after the last treatment. Results Primary outcome: 2-week recovery rate per protocol. Secondary outcome: Cumulative recovery rate and Dizziness Handicap Inventory (DHI) scores after 3 months per protocol (HSB and ML) and intention to treat (all groups).Fifty-four patients were analyzed after 2 weeks (HSB = 17; ML = 20; SM = 17). Two-week recovery rate was 14/17 after HSB, 11/20 after ML, and 4/17 after SM, with significantly better recovery in HSB [OR 15.17, 95% CI (1.85, 124.63), P = .001] using sham as base level. Recovery rate after 3 months was 15/17 after HSB and 15/19 after ML. Cumulative recovery rate showed no significant differences between the two treatment groups [95% CI (0.30, 13.14), P = .46] in cure rate DHI [95% CI (-16.56, 15.02), P = .92]. No unexpected adverse events were observed. Conclusion Velocity change in horizontal canal BPPV treatment gives a faster initial recovery. Rapid recovery could reduce the disease burden. Trial registration Clinicaltrials.gov. Identifier: NCT01905800. Level of evidence 1b.

Background In benign paroxysmal positional vertigo (BPPV), the otolithic debris may alter the dynamics of the endolymph or cupula during head-shaking. This dynamic may generate head-shaking nystagmus (HSN) but exact pathomechanism of HSN in BPPV has not been elucidated. The association of positional nystagmus induced by head-bending or lying-down with HSN may help to understand the dynamics of HSN. Objective To assess the presence, pattern, and relationship with head-bending nystagmus (HBN) and lying-down nystagmus (LDN) of HSN in horizontal canal (HC)-BPPV. Methods We recruited 173 patients with HC-BPPV (76 geotropic and 97 apogeotropic). We analyzed the pattern of HSN, and correlation with HBN and LDN. Results Half of patients (83/173, 48%) with HC-BPPV showed HSN. The directional preponderance of HSN was also not found in patients with geotropic or apogeotropic HC BPPV (p = 0.488). The presence of HSN was related with the occurrence of HBN in both geotropic (p = 0.005) and apogeotropic type (p = 0.001). The direction of HSN was same with HBN and was opposite to LDN in both geotropic and apogeotropic type. Conclusions HSN was frequently found in patients with HC-BPPV and related with HBN and LDN. HSN in BPPV might be contributed by the otolith movements related with endolymph dynamics.

This meta-analysis aims to systematically measure the immediate efficacy of the Gufoni maneuver for horizontal canal benign paroxysmal positional vertigo (HC-BPPV).A extensive search electronic databases, including PubMed, Embase, Web of Science and Cochrane library, were searched until to September 1, 2018 for relevant articles. We selected only randomized clinical trials studying with treatment of HC-BPPV employ by the Gufoni maneuver.Five randomized clinical trials were included in the current meta-analysis with a total of 714 HC-BPPV patients. The meta-analysis revealed that Gufoni maneuver had a higher immediate recovery rate than sham maneuver in treatment of HC-BPPV (risk ratio = 2.68, 95% CI, 1.54-4.65, p 0.01). No difference was observed in immediate recovery rate between Gufoni maneuver and other maneuvers (risk ratio = 1.18, 95% CI, 0.99-1.41, p = 0.06). And Gufoni maneuver had a similar otolith switch rate with other maneuvers (risk ratio = 2.13, 95% CI, 0.56-8.07, p = 0.27).Gufoni maneuver has a satisfactory immediate efficacy for HC-BPPV and does not increase otolith switch rate.

The purpose of this case report was to describe the evaluation and management of atypical benign paroxysmal positional vertigo (BPPV) in an adult with severe osteogenesis imperfecta. A 29-year-old male was referred to a physical therapist with extensive experience in vestibular rehabilitation who provided horizontal canal BPPV treatment with a canalith repositioning maneuver over two treatment sessions. The individual's symptoms had reduced by 65% and his nystagmus during the roll test was reduced. Extreme care is needed to safely reposition individuals living with severe osteogenesis imperfecta, but the repositioning can reduce symptoms and improve quality of life. Laryngoscope, 130:2241-2244, 2020.

Purpose: To determine the effectiveness of our treatment protocol for geotropic and apogeotropic horizontal canal benign paroxysmal positional vertigo (h-BPPV).Methods: We retrospectively evaluated patients with newly diagnosed geotropic and apogeotropic h-BPPV who visited our clinic between July 2017 and December 2019. Patients were treated according to our treatment protocol, which was implemented in 2017. Patients with geotropic h-BPPV were preferably treated with the Gufoni maneuver. In patients with apogeotropic h-BPPV we executed the modified Gufoni maneuver to achieve conversion to the geotropic type. We looked at the number of successful treatments and the number of recurrences within 1 year.Results: We included 102 patients with h-BPPV, 62 (61%) of whom were treated for geotropic h-BPPV. The ratio of apogeotropic to geotropic h-BPPV was 0.65. After the first visit, we observed resolution of horizontal canal BPPV in 71 and 63% of the geotropic and the apogeotropic group, respectively. After the second visit, this percentage increased to 92% for geotropic h-BPPV and 78% for apogeotropic h-BPPV. After 1 year of follow-up we determined a recurrence rate of 32 and 24% for the geotropic and apogeotropic group, respectively.Conclusion: With our treatment protocol we managed to achieve high rates of symptom resolution in the geotropic and apogeotropic type of h-BPPV with acceptable recurrence rates. We observed a relatively high ratio of apogeotropic h-BPPV to geotropic h-BPPV.

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder that is diagnosed based solely on clinical findings. Rarely, central lesions can present with positional vertigo and nystagmus, mimicking BPPV. Recognised red flags that may help distinguish central mimics from BPPV include the presence of additional neurological symptoms and signs, atypical nystagmus patterns, and the absence of a sustained response to repositioning manoeuvres. We present seven cases that illustrate how heuristic bias may affect the detection of these features in practice. Furthermore, our cases suggest that isolated downbeat positional nystagmus (simulating anterior canal BPPV) and apogeotropic horizontal nystagmus on the supine roll test (simulating horizontal canal BPPV) should be considered additional red flags.

Objective: To describe a case of benign paroxysmal positional vertigo (BPPV) resulting in reversible horizontal semicircular canalith jam successfully treated with horizontal canal occlusion. A brief literature review of similar cases was performed. Methods: Case report and literature review. Results: A 68-year-old female presented with apogeotropic positional nystagmus, attributed to reversible horizontal canalith jam mimicking cupulolithiasis that was refractory to tailored repositioning maneuvers across months. She was unable to work due to the severity of her symptoms. She underwent surgical occlusion of the affected canal with immediate resolution of her symptoms. A literature review revealed similar cases of canalith jam mimicking cupulolithiasis. Conclusions: Reversible canalith jam, in which particles moving with horizontal head position alternate between obstructing the semicircular canal and resting on the cupula, can mimic signs of cupulolithiasis. This variant of BPPV can be effectively managed with surgical canal occlusion should symptoms fail to resolve after tailored repositioning maneuvers.

OBJECTIVES The purpose of this study was to identify the diverse patterns of nystagmus during the Dix-Hallpike test (DHT) and analyze their clinical significance in horizontal canal benign paroxysmal positional vertigo (HC-BPPV). STUDY DESIGN Retrospective medical records review. PATIENTS Two hundred ninety-five patients diagnosed with HC-BPPV. METHODS Various nystagmus patterns identified during the DHT in patients with HC-BPPV were analyzed. The correlation between the affected side of HC-BPPV and the direction of the horizontal beating nystagmus (HBN) during the DHT was also analyzed. RESULTS The nystagmus pattern during the DHT in 128 patients with geotropic HC-BPPV demonstrated, direction-changing positional nystagmus on both sides in 48 (37.5%) patients, HBN toward one side in 25 (19.6%) patients, and no nystagmus in 55 (42.9%) patients. In 144 patients with apogeotropic HC-BPPV, 54 (37.5%) patients presented with direction-changing positional nystagmus on both sides, 27 (18.8%) patients presented with HBN toward one side, and 63 (43.7%) patients did not show nystagmus during the DHT. The direction of HBN provoked by the DHT was significantly correlated with the affected side in each subtype of HC-BPPV (geotropic type, p = 0.049; apogeotropic type, p = 0.040; respectively). CONCLUSION More than half of the patients with HC-BPPV (56.6%) showed HBN during the DHT. When HBN was present during the DHT, it may provide a clue for determining the subtype and affected side in diagnosis of HC-BPPV before performing the supine roll test.

Background: Patients with vestibular schwannoma that show residual peripheral-vestibular function before surgery may experience sudden and substantial vestibular loss of function after surgical resection. To alleviate the sudden loss of peripheral-vestibular function after vestibular-schwannoma (VS) resection, pre-surgical intratympanic gentamicin application was proposed.Objective: We hypothesized that this approach allows for a controlled reduction of peripheral-vestibular function before surgery but that resulting peripheral-vestibular deficits may be canal-specific with anterior-canal sparing as observed previously in systemic gentamicin application.Methods: Thirty-four patients (age-range = 27–70 y) with unilateral VS (size = 2–50 mm) were included in this retrospective single-center trial. The angular vestibulo-ocular reflex (aVOR) was quantified before and after (29.7 ± 18.7 d, mean ± 1SD) a single or two sequential intratympanic gentamicin applications by use of video-head-impulse testing. Both aVOR gains, cumulative saccadic amplitudes, and overall aVOR function were retrieved. Statistical analysis was done using a generalized linear model.Results: At baseline, loss of function of the horizontal (20/34) and posterior (21/34) canal was significantly (p < 0.001) more frequent than that of the anterior canal (5/34). After gentamicin application, loss of function of the horizontal (32/34) or posterior (31/34) canal remained significantly (p ≤ 0.003) more frequent than that of the anterior canal (18/34). For all ipsilesional canals, significant aVOR-gain reductions and cumulative-saccadic-amplitude increases were noted after gentamicin. For the horizontal canal, loss of function was significantly larger (increase in cumulative-saccadic-amplitude: 1.6 ± 2.0 vs. 0.8 ± 1.2, p = 0.007) or showed a trend to larger changes (decrease in aVOR-gain: 0.24 ± 0.22 vs. 0.13 ± 0.29, p = 0.069) than for the anterior canal.Conclusions: Intratympanic gentamicin application resulted in a substantial reduction in peripheral-vestibular function in all three ipsilesional canals. Relative sparing of anterior-canal function noted at baseline was preserved after gentamicin treatment. Thus, pre-surgical intratympanic gentamicin is a suitable preparatory procedure for reducing the drop in peripheral-vestibular function after VS-resection. The reasons for relative sparing of the anterior canal remain unclear.

Lesions at three possible sites can masquerade as apogeotropic horizontal semicircular canal benign paroxysmal positional vertigo (HSC-BPPV), namely: 1) short anterior (ampullary) arm canalolithiasis; and 2) culpulolithiasis, which may be either canal (Cup-C) or utricle-sided (Cup-U). There are no clinical methods or investigations to determine the exact pathological site when a patient with a history compatible with HSC-BPPV is found to have apogeotropic positional nystagmus on the supine roll test. Therefore, the treatment of apogeotropic variant of HSC-BPPV not only poses difficulties but the therapeutic options need to be tailored according to the ostensible localization of the pathology. If the apogeotropic HSC-BPPV is transformed into the geotropic variant, it becomes relatively easier to treat, as the treatment options for the latter are very well established. There are reports of cases of the apogeotropic variant of HSC-BPPV being transformed inadvertently during diagnostic positional tests as well as during therapeutic (intention-to-treat) positional maneuvers. I report here a case of an apogeotropic variant of right HSC-BPPV, that transformed into a geotropic variant during the therapeutic (intention-to-treat) Appiani maneuver, which was subsequently successfully treated with two sequences of Gufoni maneuver after transformation. The patient was followed up at one and 24 hours after the second sequence of Gufoni maneuver with a diagnostic supine roll test, which was negative. The case report is supported by seven videos of the diagnostic and therapeutic positional maneuvers revealing positional nystagmus, its appearance, change, and disappearance as clinical events unfolded during the examination and treatment.

Objectives: To analyze the clinical characteristics of patients with benign paroxysmal positional vertigo (BPPV) diagnosed based on the diagnostic criteria of Bárány Society, verify the clinical application value of the diagnostic criteria, and further explore the clinical problems associated with the diagnosis of possible BPPV.Methods: A total of 481 patients with BPPV who were admitted from March 2016 to February 2019 were included. All patients were diagnosed by the Dix-Hallpike, straight head hanging and supine roll tests, the nystagmus was recorded using videonystagmography. For patients with possible BPPV (uncertain diagnosis), particle repositioning therapy and follow-up diagnosis were used to further clarify diagnosis.Results: Based on Bárány Society's diagnostic criteria for BPPV, the distribution characteristics of different BPPV types were as follows: 159 (33.1%) patients had posterior canal BPPV-canalolithiasis (PC-BPPV-ca), 70 (14.6%) patients had horizontal canal BPPV-ca (HC-BPPV-ca), 55 (11.4%) patients had spontaneously resolved-probable-BPPV (Pro-BPPV), and 53 (11.0%) patients had HC-BPPV-cupulolithiasis (HC-BPPV-cu). In emerging and controversial BPPV, 51 (10.6%) patients had multiple canal BPPV (MC-BPPV), 30 (6.2%) patients had PC-BPPV-cu, and 19 (4.0%) patients had anterior canal BPPV-ca (AC-BPPV-ca), 44 (9.1%) patients had possible-BPPV (Pos-BPPV). Among the 44 patients with Pos-BPPV, 23 patients showed dizziness/vertigo without nystagmus during the initial positional test, five patients were possible MC-BPPV, four patients had persistent geotropic positional nystagmus lasting > 1 min when lying on both sides, and were considered to have Pos-HC-BPPV, four patients showed apogeotropic nystagmus when lying on one side, and were considered to have possible short-arm HC-BPPV, four patients showed geotropic nystagmus when lying on one side, and were considered to have Pos-HC-BPPV, three patients had down-beating nystagmus, lasing > 1 min, were considered to have Pos-AC-BPPV-cu. One patient showed transient apogeotropic positional nystagmus on both sides during the supine roll test, and was diagnosed with possible anterior arm HC-BPPV.Conclusions: PC-BPPV-ca is the most common among patients with BPPV, followed by HC-BPPV-ca. In emerging and controversial BPPV, MC-BPPV, and Pos-BPPV were more common. For the diagnosis of Pos-BPPV, a combination of the history of typical BPPV, particle repositioning therapy and follow-up outcome is helpful to clarify the diagnosis.

KEY POINTS1.Our population represents a common clinical scenario in which auditory profiles do not determine eligibility for further evaluation.2.Mean VOR gain in the VS group, was significantly lower on the affected side in the three canal planes.3.Refixation saccades in the affected horizontal canal had a significantly higher latency and velocity in the VS group.4. When we categorized the presence of the VIN with mastoid stimulation, we yielded sensitivities of 81.8% and specificities of 73.9% for detecting VS.5.The VIN test causes minor discomfort with high diagnostic accuracy and should be considered before referring for further imaging.

Objective: To elucidate the frequency, underlying mechanisms, and clinical implications of spontaneous reversal of positional nystagmus (SRPN) in benign paroxysmal positional vertigo (BPPV).Methods: We prospectively recruited 182 patients with posterior canal (PC, n = 119) and horizontal canal (HC) BPPV (n = 63) canalolithiasis. We analyzed the maximal slow phase velocity (maxSPV), duration, and time constant (Tc) of positional nystagmus, and compared the measures between groups with and without SRPN. We also compared the treatment outcome between two groups.Results: The frequency of SRPN in PC- and HC-BPPV was 47 and 68%, respectively. The maxSPVs were greater in BPPV with SRPN than without, larger in HC-BPPV than PC-BPPV (114.3 ± 56.8 vs. 57.1 ± 38.1°/s, p < 0.001). The reversed nystagmus last longer in HC-BPPV than PC-BPPV. The Tc of positional nystagmus got shorter in PC-BPPV with SRPN (3.7 ± 1.8 s) than without SRPN (4.5 ± 2.0 s, p = 0.034), while it was longer during contralesional head turning in HC-BPPV with SRPN (14.8 ± 7.5 s) than that of ipsilesional side (7.3 ±2.8 s, p < 0.001). The treatment response did not significantly differ between groups with and without SRPN in both PC- and HC-BPPV (p = 0.378 and p = 0.737, respectively).Conclusion: The SRPN is common in both PC- and HC-BPPV canalolithiasis. The intensity of rotational stimuli may be a major determinant for the development of short-term central adaptation which utilizes the velocity-storage system below a certain velocity limit. The presence of SRPN is not related to treatment outcome in BPPV.

Backgrounds: Although various therapeutic maneuvers have been proposed, it is still unclear which maneuver is better to treat apogeotropic horizontal canal benign paroxysmal positional vertigo (HC-...

Purpose This study aimed to retrospectively evaluate the efficacy of Li Maneuver as a repositioning maneuver for geotropic HC-BPPV, compared with Gufon Maneuver. Methods Data of geotropic HC-BPPV patients treated at our department between January 2009 and January 2020 was retrospectively collected and analyzed. Enrolled cases were divided into Gufoni Group and Li Group. Follow-up results were recorded on the first, third, and seventh day after the first therapeutic maneuver. Results A total of 254 cases were enrolled, with 87 cases in Gufoni Group, and 167 cases in Li Group. The cure rate at the first, third, and seventh days of follow-up was 62.22%, 77.01%, and 90.80% respectively for Gufoni Group, while for Li Group the number was 60.48%, 72.46%, and 89.22% respectively. Statistical analysis showed no significant difference. Conclusions Li Maneuver for geotropic HC-BPPV was as effective as Gufoni Maneuver but much simpler and faster. By introducing Li Maneuver, we may help physicians to treat geotropic HC-BPPV patients more willingly, which would decrease the chance of delayed treatment and ease the burden of the health-care system.

Introduction Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo, and it is characterized by episodes of vertigo roundabout when the head is moved. A systematic review was performed using the most important scientific databases. This review included studies published in English in the last ten years, performed in adults, with emphasis on the diagnosis and treatment of BPPV. Objective To investigate the long-term effectiveness of vestibular rehabilitation (VR) in patients with BPPV and the rate of recurrence of symptoms. Data Synthesis A total of 38 studies were identified, of which only 12 met the inclusion criteria. The majority of the studies stated that VR is effective in decreasing the symptoms, with a short-term efficacy of 84.7%, and 89.2% in the long term in the reviewed studies. Conclusion Valuable studies show the beneficial effects of the maneuvers for the treatment of BPPV and their long-term effectiveness. This strengthens the conclusion that this treatment is effective in resolving symptoms and decreasing recurrences.

Objective In this retrospective study, the aim of the authors was to examine the frequency of involvement of the individual semicircular canals (SCCs) in vestibular neuritis (VN) and to assess the degree of long-term recovery. A secondary aim was to retrospectively determine the usefulness of a three-step bedside oculomotor test (the HINTS-test) for the differential diagnosis of peripheral VN. Methods 44 cases were evaluated during the acute phase and approximately two months later. The gain of the vestibuloocular reflex was determined using video-head-impulse test, carried out using Otometrics ICS Impulse Otosuite Vestibular V 1.2. Results In 19 cases (43%), a typical, so called “superior” VN could be diagnosed; in 17 cases (38%), all three SCCs were involved; in 4 cases, an isolated inferior canal involvement was seen; and in another 4 cases, a slight, isolated horizontal canal involvement was registered. Slight, isolated horizontal canal vestibular neuritis causing acute vestibular syndrome has not yet been reported in the literature. A three-step bedside oculomotor examination, the HINTS-test (head-impulse test, examination of gaze evoked nystagmus, and test of skew-deviation), suggested peripheral involvement in all cases with superior pattern VN and in cases when all three SCC were involved. It indicated ‘stroke’ in cases with inferior pattern and in the cases with isolated involvement of the horizontal canal. At follow-up, the horizontal canal function normalized in 55%, the anterior canal in 38%, and the inferior in 38%. When all cases were pooled, 14 patients recovered completely. In cases with severe initial decrease of gain in the horizontal canal (initial value less than 0.5), the canals had a 50 per cent chance to recover significantly. Conclusion In vestibular neuritis, in cases with severe decrease of gain in the horizontal canal (initial value less than 0.5), the canal has a 50 per cent chance to recover significantly. The vertical canals have worse prognosis, and especially the inferior canals seldom improve. Slight, isolated horizontal canal vestibular neuritis may cause acute vestibular syndrome, most probably by the same mechanism as full-blown vestibular neuritis. In these cases, the three-step bedside oculomotor test may indicate cerebellar stroke (may be false positive).

Background and Purpose: In the horizontal canal benign paroxysmal positional vertigo (BPPV), cupulolithiasis shows apogeotropic direction changing nystagmus lasting more than 1 min, while canalolithiasis leads to geotropic direction changing nystagmus lasting < 1 min. The difference between cupulolithiasis and canalolithiasis is widely accepted to be the attachment of the displaced otoconia to the cupula of a semicircular canal. Several studies have shown a relationship between BPPV and vitamin D deficiency, but no studies have compared serum levels of vitamin D between canalolithiasis and cupulolithiasis patients. The purpose of this study was to clarify the difference in vitamin D serum level between canalolithiasis and cupulolithiasis of the horizontal canal. Methods: This retrospective study included 20 and 15 patients with canalolithiasis and cupulolithiasis of the horizontal canal, respectively. Serum levels of 25-hydroxyvitamin D [25(OH)D] during the acute phase of BPPV were measured. Results: The mean 25(OH)D serum level in patients with canalolithiasis and cupulolithiasis was 13.2 ± 1.4 and 20.4 ± 1.6 ng/mL, respectively, and the difference was statistically significant (p = 0.0014), also after adjusting for age and sex (p = 0.0351). Eighteen out of 20 (90%) and 5 of 15 (33%) patients were diagnosed with vitamin D deficiency in the canalolithiasis and cupulolithiasis groups, respectively, and this difference was also statistically significant (p = 0.0005). Conclusion: We found that serum vitamin D level in patients with canalolithiasis was significantly lower than that in patients with cupulolithiasis of the horizontal canal.

BACKGROUND Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder affecting about 20% of dizzy patients. Early diagnosis and treatment can improve the quality of life for patients. OBJECTIVE We reviewed the classifications of different subtypes of benign paroxysmal positional vertigo and the problems we encountered using the diagnostic criteria of the Barany Society. METHODS Both the Dix-Hallpike maneuver and supine roll test were performed on 568 patients, and diagnoses were made based on patient history and the type of provoked nystagmus (if any). Next, the numbers of patients with each subtype and other parameters, including age and sex, were analyzed. RESULTS Posterior semicircular canal BPPV (pc-BPPV) accounted for the largest proportion, followed by horizontal semicircular canal BPPV (hc-BPPV). Both anterior canal BPPV and multiple canal lithiasis BPPV were rare, and no patient was diagnosed with cupulolithiasis of the posterior canal. CONCLUSIONS pc-BPPV, hc-BPPV, and cupulolithiasis of the horizontal canal (hc-BPPV-cu) were the three major subtypes that could be definitively diagnosed, whereas the diagnoses of possible benign paroxysmal positional vertigo (pBPPV) and probable benign paroxysmal positional vertigo [spontaneously resolved] (pBPPVsr) require further investigation, with special attention being paid to appropriate differentiation and repositioning maneuvers.

To define the best up-to-date practical approach to treat benign paroxysmal positional vertigo (BPPV). Both posterior and horizontal canal BPPV canalith repositioning maneuvers (Semont, Epley, and Gufoni’s maneuvers) are level 1 evidence treatment for evidence-based medicine. The choice of maneuver (since their efficacy is comparable) is up to the clinician’s preferences, failure of the previous maneuver, or movement restrictions of the patient. Maneuvers for controversial variants, such as anterior canal and apogeotropic posterior canal BPPV, have weaker evidence of efficacy. Despite this, these variants are increasingly diagnosed and treated. Maneuvers also play a role in the differential diagnosis with central vestibular disorders. Chair-assisted treatment may be of help if available while surgical canal plugging should be indicated in selected same-canal, same-side intractable severe BPPV. The primary evidence-based treatment strategy for BPPV should be physical therapy through maneuvers. Despite the high success rate of liberatory maneuvers, there is a low percentage of subjects who have unsatisfactory outcomes. These patients need to be investigated to identify recurrences, multiple canal involvement, associated comorbidities (migraine, persistent postural perceptual dizziness), or risk factors for recurrences (low vitamin D serum level). Future research should also identify the optimum maneuvers for variants whose diagnosis and treatment are still a matter of some debate.

In the article, “Questionnaire-based diagnosis of benign paroxysmal positional vertigo (BPPV),” Kim et al. presented a study of a 6-item questionnaire developed for the diagnosis of BPPV, with the first 3 questions intended to identify BPPV and the next 3 intended to determine the involved canal and type of BPPV. Among 578 patients who completed the questionnaire before positional tests at a dizziness clinic, the questionnaire could diagnose BPPV with a sensitivity of 87.0% and specificity of 89.8%. The questionnaire and positional tests showed similar results in identifying the BPPV subtype and the affected side. In response, Drs. Gold and Newman-Toker noted that although BPPV itself can often be diagnosed by history, the physical examination is traditionally key to identify the site of the culprit otoliths. Although hailing the questionnaire-based method as an important step forward, they raise questions about its reproducibility—particularly in other care settings—and about its potential to facilitate self-treatment by patients at home. In another response, Dr. Lanska is skeptical of the questionnaire's utility for identifying the type of BPPV and contends that the proportion of horizontal canal BPPV (HC-BPPV) was atypically high—potentially because of referral bias—thereby lowering the predicted accuracy of simply classifying all questionnaire-positive cases as the posterior canal subtype (PC-BPPV). Dr. Lanska suggests using a simpler 4-question strategy focused on making a diagnosis of BPPV (presuming a posterior canal [PC] BPPV subtype), determining the side, and pursuing referral to a vestibular expert only if initial side-appropriate self-treatment maneuvers are unsuccessful. Responding to these comments, the authors acknowledge the need to further evaluate the generalizability of their results to other clinical settings and note that they are conducting a clinical trial on the self-application of canalith repositioning maneuvers by patients based on questionnaire results. The authors acknowledge that the PC is much more commonly involved in BPPV but caution against underestimating the frequency of HC-BPPV. However, they acknowledge the potential benefit of a simpler 4-question approach, particularly in practices with a higher PC-BPPV prevalence and note that its performance could be compared with their six-question strategy in further studies. This exchange highlights the potential for questionnaire-based strategies to facilitate diagnosis and streamline referral pathways for common neurologic conditions such as BPPV. In the article, “Questionnaire-based diagnosis of benign paroxysmal positional vertigo (BPPV),” Kim et al. presented a study of a 6-item questionnaire developed for the diagnosis of BPPV, with the first 3 questions intended to identify BPPV and the next 3 intended to determine the involved canal and type of BPPV. Among 578 patients who completed the questionnaire before positional tests at a dizziness clinic, the questionnaire could diagnose BPPV with a sensitivity of 87.0% and specificity of 89.8%. The questionnaire and positional tests showed similar results in identifying the BPPV subtype and the affected side. In response, Drs. Gold and Newman-Toker noted that although BPPV itself can often be diagnosed by history, the physical examination is traditionally key to identify the site of the culprit otoliths. Although hailing the questionnaire-based method as an important step forward, they raise questions about its reproducibility—particularly in other care settings—and about its potential to facilitate self-treatment by patients at home. In another response, Dr. Lanska is skeptical of the questionnaire's utility for identifying the type of BPPV and contends that the proportion of horizontal canal BPPV (HC-BPPV) was atypically high—potentially because of referral bias—thereby lowering the predicted accuracy of simply classifying all questionnaire-positive cases as the posterior canal subtype (PC-BPPV). Dr. Lanska suggests using a simpler 4-question strategy focused on making a diagnosis of BPPV (presuming a posterior canal [PC] BPPV subtype), determining the side, and pursuing referral to a vestibular expert only if initial side-appropriate self-treatment maneuvers are unsuccessful. Responding to these comments, the authors acknowledge the need to further evaluate the generalizability of their results to other clinical settings and note that they are conducting a clinical trial on the self-application of canalith repositioning maneuvers by patients based on questionnaire results. The authors acknowledge that the PC is much more commonly involved in BPPV but caution against underestimating the frequency of HC-BPPV. However, they acknowledge the potential benefit of a simpler 4-question approach, particularly in practices with a higher PC-BPPV prevalence and note that its performance could be compared with their six-question strategy in further studies. This exchange highlights the potential for questionnaire-based strategies to facilitate diagnosis and streamline referral pathways for common neurologic conditions such as BPPV.

Kim et al.'s1 6-question strategy to diagnose benign paroxysmal positioning vertigo (BPPV) provides “acceptable” accuracy for BPPV diagnosis but less utility for type of BPPV. Reported accuracy of question 4—“to distinguish horizontal canal (HC) from posterior canal (PC) BPPV”—is largely due to vastly different frequencies of BPPV types.

The aim of the study is to evaluate the efficiency of the new repositioning maneuver for patients with horizontal canal cupulolithiasis benign paroxysmal positional vertigo (BPPV) to perform independently at home between doctor's sessions.28 patients with isolated horizontal canal cupulolithiasis BPPV were enrolled. In all of them treatment with Gufoni maneuver was not successful after first session. They were divided in M«-» group (17 patients), M«-» group (11 patients). M«-» group performed forced prolong prositionig on the side with less dizziness between sessions. M«-» group performed forced prolong prositionig on the side with less dizziness and 3-5 repetitions of new repositioning maneuver 2-3 times a day between sessions. Repositioning maneuver consists of head shaking, then moving to one side-lying position with maintaining it until dizziness stops and resuming the upright sitting position, then without a pause performing head shaking and moving to the other side-lying position with maintaining it until dizziness stops and resuming the upright sitting position. The patients visited doctor once a week. Before treatment and 1 week after treatment dizziness handicap inventory (DHI) was administrated.After 2 and 3 weeks of treatment more patients in M«-» group than in M«-» group were cured (Recovery from horizontal canal cupulolithisis BPPV could be achieved at an early date with self-performing of new repositioning maneuver. Patient-perceived disability in persisting horizontal canal cupulolithiasis could be less if the new repositioning maneuver is performed.Оценка эффективности нового репозиционного маневра для самостоятельного выполнения пациентами дома между приемами врача при купулолитиазе горизонтального полукружного канала (ГПК).28 пациентов с доброкачественным пароксизмальным позиционным головокружением (ДППГ), изолированным купулолитиазом ГПК, у которых не произошло выздоровление после проведения репозиционного маневра Gufoni на первом приеме врачом, были разделены на группы М«–» (17 человек) и М«+» (11). Пациенты М«–» группы между приемами врача выполняли длительное вынужденное лежание на боку, на котором они испытывают менее выраженное головокружение, во время ночного сна. Пациенты М«+» группы между приемами, помимо длительного вынужденного лежания во время ночного сна, выполняли новый репозиционный маневр 3—5 раз подряд по 2—3 раза в день. Репозиционный маневр заключается в встряхивании головы с последующим укладыванием на один бок и сохранением этого положения до окончания головокружения и последующим возвращением в исходное положение, после чего без паузы проводится повторное встряхивание головы и укладывание на другой бок с сохранением этого положения до прекращения головокружения и последующим возвращением в исходное положение. Повторные приемы врачом осуществлялись через 1 нед. Перед началом лечения и через 1 нед лечения проводилась оценка интенсивности головокружения по шкале оценки головокружения.Через 2 и 3 нед после начала лечения в М«+» группе по сравнению с М«–» группой отмечено достоверно больше выздоровевших пациентов (При лечении купулолитиаза ГПК с использованием нового репозиционного маневра для самостоятельного выполнения выздоровление достигается в более ранние сроки, а также наблюдается уменьшение субъективного ощущения головокружения по шкале DHI даже при отсутствии разрешения отолитиаза.

Canalith jam refers to a condition caused by an otolithic clump blocked inside a semicircular canal, generally provoked by canalith repositioning procedure. We describe the first case of spontaneous canalith jam mimicking an acute vestibular deficit.We report the case of an 82-year-old woman who suffered a sudden episode of persistent rotational vertigo with nausea and vomiting, not provoked by head movements.Videonystagmography revealed a horizontal right-beating spontaneous nystagmus, inhibited by visual fixation. Surprisingly, the positional test showed a direction changing apogeotropic horizontal nystagmus weaker in the left side, compatible with a left side horizontal canal canalolithiasis of the apogetropic type. Returning to the sitting position, a spontaneous nystagmus was observed again, not tilt sensitive. A left side caloric paresis was found.After performing liberatory maneuvers, the spontaneous nystagmus disappeared and a horizontal canal benign paroxysmal positional vertigo of geotropic type was documented. The canal paresis also disappeared.Canalith jam is rarely described and is overall observed as a repositioning manoeuvre complication, not as a mimicker of a vestibular neuritis. Furthermore, our case represents the first observation of a recurrent canalith jam and apogeotropic variant of horizontal canal benign paroxysmal positional vertigo.

Li quick repositioning maneuver for treatment of geotropic horizontal canal benign paroxysmal positional vertigo (HC-BPPV) was reported in the literature.The aim of this study is to observe the clinical efficacy of the Li quick repositioning maneuver for the treatment of geotropic HC-BPPV.The single-blind method was used to conduct a prospective controlled study on 120 patients with geotropic HC-BPPV from May 2014 to May 2017. Patients were randomly assigned to the Li quick repositioning maneuver (Li maneuver) group or the barbecue repositioning maneuver (barbecue maneuver) group.The successful repositioning rates were 53.3%, 70.4%, 90.7% and 92.3%, respectively, in barbecue maneuver group and 61.7%, 80.7%, 93.0% and 96.3%, respectively, in Li maneuver group at 1-day, 3-day, 1-week and 1-month follow-up. Differences in success rates of repositioning between Li and barbecue maneuver groups at 1 day, 3 days, 1 week and 1 month after initial treatment were not statistically significant using the Kaplan-Meier survival curve with a log-rank test (p = .270) .The Li maneuver is a rapid, simple and efficacious repositioning method for geotropic HC-BPPV and can be widely applied in clinical practice as an alternative method.

Five to ten percent of benign paroxysmal positional vertigo are caused by the horizontal semi-circular variant (h-BPPV). In this study, we reviewed the efficacy of the Barbecue repositioning manoeuvre in h-BPPV, and we assessed the possible effect of different factors on the outcome. Barbecue manoeuvre consists in turning the supine patient around his longitudinal axis toward the unaffected side until 360 degrees are accomplished. After every 90 degrees step the patient is maintained in the new position for 30 s. We reviewed 46 patients with h-BPPV, treated by barbecue rotation from 2003 to 2005. After the first Barbecue manoeuvre, the patients were followed-up at intervals of approximately 1 week and the rotation was repeated if h-BPPV persisted (up to three rotations). Factors assessed were age, gender, duration of symptoms before treatment and type of h-BPPV (canalolithiasis vs. cupulolithiasis). Fisher's exact test was used for the analysis. Results: 85% of patients (39/46) were cured after a maximum of 3 rotations. 74% (34/46) were cured after the first manoeuvre and 80% (37/46) after the second one. None of the evaluated factors did significantly affect the efficacy (P > 0.05). The Barbecue manoeuvre is an efficient treatment of h-BPPV demonstrating 85% cure rate after a maximum of three sessions. 74% of the patients are healed after one manoeuvre. The efficacy is not affected by the evaluated factors.

OBJECTIVE We investigated the neuro-otological findings, including nystagmus, and the clinical course of patients with the horizontal canal variant of benign paroxysmal positional vertigo (HC-BPPV), who showed spontaneous inversion of nystagmus without a positional change. Furthermore, we speculated on the possible mechanism of spontaneous inversion of nystagmus without a positional change. PATIENTS AND METHODS The characteristics of spontaneous inversion of positional nystagmus without a positional change were analyzed in 7 patients with HC-BPPV. RESULTS All patients were diagnosed as having HC-BPPV. During the positional test, the spontaneous inversion of nystagmus was observed in the same head position in all patients. Spontaneous inversion was observed on both sides in 5 patients, and only on 1 side in 2 patients. All patients presented with geotropic nystagmus in the first phase, and ageotropic nystagmus in the second phase. CONCLUSIONS The coexistence of cupulolithiasis and canalolithiasis appears to be a possible mechanism of the spontaneous inversion of positional nystagmus.

Benign paroxysmal positional vertigo (BPPV), the most frequent cause of vertigo is associated with high morbidity in the elderly population. The most common form is linked to debris in the posterior semicircular canal. However, there has been an increasing number of reported BPPV cases involving the horizontal canals. The purpose of this article is to highlight the clinical features, diagnosis, and treatment in 37 patients with horizontal canal BPPV; twenty-six with geotropic nystagmus, and eleven with the apogeotropic form. Treatment consisted of the Gufoni manoeuver in eighteen patients (48.6%), the barbecue 360° maneuver in twelve patients (32.4%), both manoeuvers in four patients (10.8%), both manoeuvers plus head shaking in one patient (2.7%), and the Gufoni maneuver plus head shaking in two patients. Cupulolithiasis patients were asked to sleep in a forced prolonged position. We obtained a complete resolution of vertigo and nystagmus in 30 patients (81.0%) on the initial visit. Vertigem posicional paroxística benigna (VPPB) é a causa mais frequente de vertigem e promove alta morbidade na população idosa. A forma mais comum está relacionada com otoconias no canal semicircular posterior. Entretanto, nos últimos anos identifica-se cada vez mais casos de VPPB dos canais horizontais. Os principais objetivos deste artigo são destacar as características clínicas, diagnóstico e tratamentos aplicados em 37 pacientes com VPPB do canal horizontal; vinte e seis com nistagmo geotrópico, e onze com nistagmo apogeotrópico. O tratamento consistiu na manobra de Gufoni em dezoito pacientes (48,6%) manobra do churrasco 360° em doze pacientes (32,4%) ambas as manobras em quatro pacientes (10,8%) ambas as manobras mais a manobra de sacudir a cabeça (MSC) em um paciente (2,7%), e manobra de Gufoni mais MSC em dois pacientes (2,7%). Pacientes com cupulolitíase dormiram uma noite na posição forçada prolongada. Em 30 pacientes (81,0%) o sucesso terapêutico ocorreu na primeira consulta.

Objectives/Hypothesis To describe the pathophysiology of horizontal canal benign paroxysmal positional vertigo, the available maneuvers for its management, and the recommended treatment. Data Sources PubMed, Cochrane library. Review Methods Review of the available literature. Results Two theories of pathophysiology underlying the disease are described, along with available maneuvers reflecting those theories; and videos of the maneuvers are provided. A comparison of available treatments is made. Conclusion A variety of maneuvers is available related to the pathophysiology underlying the disease. The treatment chosen should be appropriate to the patients' ages, general conditions, and other diseases they may have. No treatment was found to be superior over the others regarding the success rate. In the case of geotropic nystagmus, the Gufoni maneuver is superior in its ease of performance. When it comes to apogeotropic nystagmus, the Barbecue and Gufoni maneuvers have comparable success rates. Laryngoscope, 125:1959–1964, 2015

Introduction and objective: Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vertigo, characterized by brief attacks of rotatory vertigo associated with nystagmus, which are elicited by specific changes in head position relative to gravity. The observation of positional nystagmus is essential for the diagnosis of BPPV. The treatment consists in maneuvers of canalith repositioning procedure to move otoconial debris from the affected semicircular canal to the utricle. These guidelines are intended for all who treat the BPPV in their work, with an intention to assist in the diagnosis and application of an appropriate therapeutic method. Method: The experience and analysis of different national and international consensus on BPPV, has allowed to a large group of ENT specialists of the Communities of Castilla y León, Cantabria and La Rioja (Spain), carry out this guide. Results: The different clinical entities are reviewed. BPPV of the posterior semicircular canal, horizontal canal and anterior canal, BPPV affecting several canals, atypical and central BPPV, subjective BPPV and the characteristics of this process in the elderly. Canalith repositioning procedures have been illustrated with explanatory drawings. Discussion and conclusions: Although the pathophysiology of BPPV is canalolithiasis comprising free-floating otoconial debris within the endolymph of a semicircular canal, or cupulolithiasis comprising otoconial debris adherent to the cupula, there are still many issues to be resolved. We think that the best way to find answers is part of using a common methodology in the diagnosis and treatment of these patients., Introducción y Objetivo: El vértigo periférico más frecuente es el Vértigo Posicional Paroxístico Benigno (VPPB), caracterizado por bruscos ataques de sensación rotatoria, que aparecen como consecuencia de determinados cambios en la posición de la cabeza con relación a la gravedad. La observación del nistagmo posicional es fundamental para el diagnóstico de VPPB. El tratamiento consiste en aplicar maniobras de reposición, para intentar trasladar los restos otoconiales libres, desde el conducto semicircular (CS) afectado hasta el utrículo. Esta guía, está orientada para quienes tratan el VPPB, con la intención práctica de ayudarles en el diagnóstico y tratamiento de esta enfermedad. Método: La experiencia y el análisis de diferentes acuerdos nacionales e internacionales sobre el VPPB, han permitido a un amplio grupo de especialistas ORL de las Comunidades de Castilla y León, Cantabria y La Rioja (España), llevar a cabo esta guía. Resultados: Se revisan las diferentes entidades clínicas. VPPB del conducto semicircular posterior (CSP), horizontal (CSA) y anterior (CSA), incluyéndose también el VPPB multicanal, VPPB atípico y central, VPPB subjetivo y las características de este proceso en el anciano. Las maniobras de reposición se han ilustrado con dibujos explicativos. Discusión y conclusiones: Aunque la fisiopatología del VPPB se explica por la presencia de restos otoconiales libres en la endolinfa de uno o varios conductos semicirculares (canalitiasis) y en algunos casos por su adherencia a la cúpula del CS (cupulolitiasis), aún quedan muchas cuestiones por resolver. Pero creemos que la mejor manera de encontrar respuestas parte de utilizar una metodología común en el diagnóstico y tratamiento de estos pacientes.

Background: The effective management of lateral canal benign paroxysmal positional vertigo (LC-BPPV) is dependent upon the accurate identification of the affected ear. The supine roll test is the gold standard for diagnosing LC-BPPV. However, in some cases, the elicited nystagmus has a similar intensity when the head is rolled to the right or to the left. Objectives: The purpose of this systematic review was to determine the effectiveness of accessory diagnostic procedures, used in conjunction with the supine roll test, at accurately identifying the affected ear in individuals with LC-BPPV. Methods: The following databases were searched: (1) CINAHL Plus with Full Text, (2) ProQuest Medical Library, and (3) MEDLINE. The following search terms were used: (1) ‘lateral canal’ OR ‘horizontal canal’ AND (2) ‘positional vertigo’ OR ‘positioning vertigo’ OR ‘positional nystagmus’ OR ‘positioning nystagmus’. Evidence level was examined with the Oxford Centre for Evidence-Based Medicine 2011 levels of evidence meth...

OBJECTIVES To determine the characteristics and diagnostic value of pseudo-spontaneous and head-shaking nystagmus (HSN) in benign paroxysmal positional vertigo involving the horizontal semicircular canal (HC-BPPV). STUDY DESIGN Retrospective case series review. METHODS After excluding 19 patients with canal paresis, abnormal head impulse test, recent history of peripheral or central vestibular disorders, or poor cooperation, we retrospectively recruited 127 patients with HC-BPPV from January 2009 to July 2012. The patients included 69 geotropic and 58 apogeotropic types. We analyzed the pattern of pseudo-spontaneous nystagmus and HSN according to the lesion side. RESULTS Pseudo-spontaneous nystagmus was observed in 87 (87/127, 68.5%) patients, both in geotropic (46/69, 66.7%) and apogeotropic (41/58, 70.7%) types without difference in the prevalence between the types (p = 0.627). Pseudo-spontaneous nystagmus beat more to the lesion side in apogeotropic type (28/41, 68.3%, p = 0.028) but in either direction without directional preponderance in geotropic type (p = 0.659). Of the 90 patients who underwent horizontal head-shaking, 27 (30.0%) showed HSN that was more common in apogeotropic than in geotropic type (22/44 [50.0%] versus 5/46 [10.9%], p < 0.001). Patients with apogeotropic HC-BPPV showed predominantly contralesional HSN (19/22 [86.4%], p = 0.001), whereas patients with geotropic type did not show any directional preponderance of HSN (contralesional in 2 and ipsilesional in 3). CONCLUSION HSN is more common and mostly contralesional in apogeotropic HC-BPPV. HSN may be a lateralizing sign in apogeotropic HC-BPPV. Different prevalence and patterns of HSN in apogeotropic and geotropic HC-BPPV suggest dissimilar cupular dynamics in those disorders.

A 17-year-old high school boy who complained of severe positional vertigo visited our hospital. He belonged to an American football team in high school, and his head often hit opponents during games. The vertigo was strongest when his left ear was down in the supine position. Physical examination and computed tomography revealed no abnormalities. However, positional testing revealed apogeotropic direction-changing horizontal nystagmus. Rightward nystagmus in the left-ear-down supine position was stronger than leftward nystagmus in the right-ear-down supine position. Additionally, in the supine position, a null point for horizontal nystagmus was identified, beyond which the nystagmus changed direction. This null point was evident when the head was turned 10 degrees to the side. The diagnosis was right lateral canal type of BPPV caused by cupulolithiasis. He was treated with the Gufoni maneuver and reported a decreased incidence of positional vertigo upon re-evaluation.

Objectives/Hypothesis The clinical features and treatment outcomes of benign paroxysmal positional vertigo (BPPV) are known to be different depending on the type of and involved canal. This difference could be due to differences in the functional change of the otolith organ. Study Design Case series. Methods Forty-nine patients were diagnosed to primary BPPV; 18 were categorized as posterior canal canalolithiasis (PC canalolithiasis), and 31 were categorized as horizontal canal (HC) BPPV with canalolithiasis or cupulolithiasis (HC canalolithiasis or HC cupulolithiasis). Diagnostic interventions to measure vestibular functions were performed such as electronystagmography (ENG), videonystagmography (VNG), and static and dynamic subjective visual vertical (SVV). BPPV was confirmed with nystagmus during positioning/positional test under ENG and VNG. Static SVV was recorded with a light-emitting diode (LED) bar located in front of the patients before eccentric rotation and dynamic SVV was recorded during eccentric rotation with the LED bar. SVV angles were read by the examiner and analyzed. The measured values were compared to those of normal controls and each other. Results Dynamic SVV toward the lesion side in all subtypes of BPPV were significantly different from those of the controls; HC cupulolithiasis showed significantly lower values than those of PC canalolithiasis and HC canalolithiasis. Conclusions HC cupulolithiasis shows a lesser degree of utricular dysfunction compared with other subtypes. It could postulate the difference of pathophysiology between canalolithiasis and cupulolithiasis. Level of Evidence 4. Laryngoscope, 124:984–988, 2014

For horizontal canal benign paroxysmal positional vertigo, determination of the pathologic side is difficult and based on many physiological assumptions. This article reports findings on a patient who had one dysfunctional inner ear and who presented with horizontal canal benign paroxysmal positional vertigo, giving us a relatively pure model for observing nystagmus arising in a subject in whom the affected side is known a priori. It is an interesting human model corroborating theories of nystagmus generation in this pathology and also serves to validate Ewald's second law in a living human subject. Laryngoscope, 123:3197–3200, 2013

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.

BPPV when diagnosed before any repositioning procedure is called primary BPPV. Primary BPPV canalithiasis treatment with repositioning procedures sometimes results in unintentional conversion of BPPV form: transitional BPPV. Objectives were to find transitional BPPV forms, how they influence relative rate of canal involvement and how to be treated. This study is a retrospective case review performed at an ambulatory, tertiary referral center. Participants were 189 consecutive BPPV patients. Main outcome measures were detection of transitional BPPV, outcome of repositioning procedures for transitional canalithiasis BPPV and spontaneous recovery for transitional cupulolithiasis BPPV. Canal distribution of primary BPPV was: posterior canal (Pc): 85.7% (162/189), horizontal canal (Hc): 11.6% (22/189), anterior canal (Ac): 2.6% (5/189); taken together with transitional BPPV it was: Pc: 71.3% (164/230), Hc: 26.5% (61/230), Ac: 2.2% (5/230). Transitional BPPV forms were: Hc canalithiasis 58% (24/41), Hc cupulolithiasis 37% (15/41) and common crux reentry 5% (2/41). Treated with barbecue maneuver transitional Hc canalithiasis cases either resolved in 58% (14/24) or transitioned further to transitional Hc cupulolithiasis in 42% (10/24). In follow-up of transitional Hc cupulolithiasis we confirmed spontaneous recovery in 14/15 cases in less than 2 days. The most frequent transitional BPPV form was Hc canalithiasis so it raises importance of barbecue maneuver treatment. Second most frequent was transitional Hc cupulolithiasis which very quickly spontaneously recovers and does not require any intervention. The rarest found transitional BPPV form was common crux reentry which is treated by Canalith repositioning procedure. Transitional BPPV taken together with primary BPPV may decrease relative rate of Pc BPPV, considerably increase relative rate of Hc BPPV and negligibly influence relative rate of Ac BPPV. Transitional BPPV forms can be produced by repositioning maneuvers (transitional Hc cupulolithiasis) or by the subsequent controlling positional test (transitional Hc canalithiasis and common crux reentry); underlying mechanisms are discussed.