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This article presents operational diagnostic criteria for benign paroxysmal positional vertigo (BPPV), formulated by the Committee for Classification of Vestibular Disorders of the Barany Society. The classification reflects current knowledge of clinical aspects and pathomechanisms of BPPV and includes both established and emerging syndromes of BPPV. It is anticipated that growing understanding of the disease will lead to further development of this classification.

Benign paroxysmal positional vertigo (BPPV) is common, sometimes terrifying, but rarely portends serious disease. It is usually easily diagnosed and treated, and both the patient and the physician are immediately gratified. While much has been learned about the pathogenesis of BPPV in the past decades, many of its features remain mysterious, and one must still be wary of the rare times it mimics a dangerous brain disorder. Here we review common, relatively well understood clinical features of BPPV but also emphasize what we do not know and when the physician must look deeper for a more ominous cause.

OBJECTIVES/HYPOTHESIS The need for class I and II studies on the efficacy of liberatory maneuvers in the treatment of lateral canal benign paroxysmal positional vertigo (LC-BPPV) motivated the present double-blind randomized trial on the short-term efficacy of the forced prolonged position (FPP). STUDY DESIGN Double-blind, randomized controlled trial. METHODS Two hundred twenty-one patients with unilateral LC-BPPV met the inclusion criteria for a multicentric study. Patients were randomly assigned to treatment by FPP (116 subjects) or sham treatment (105 subjects). Subjects were followed up at 24 hours with the supine roll test by blinded examiners. RESULTS Among the sample, 67.4% and 32.6% of the patients showed respectively geotropic and apogeotropic variant of LC-BPPV. At the 24-hour follow-up, the effectiveness of FFP compared to the sham maneuver was, respectively, 57.8% versus 12.4% (P

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.

Meniere Disease keeps challenges in its diagnosis and treatment since was defined by Prosper Meniere at the beginning of 19th Century. Several classifications and definition were made until now and speculations still exist on its etiology. As the etiology remains speculative the treatment models remain in discussion also. The European Academy of Otology and Neurotology Vertigo Guidelines Study Group intended to work on the diagnosis and treatment of Meniere's disease and created the European Positional Statement Document also by resuming the consensus studies on it. The new techniques on diagnosis are emphasized as well as the treatment models for each stage of the disease are clarified by disregarding the dilemmas on its treatment. The conservative, noninvasive and invasive therapeutic models are highlighted.

This article presents operational diagnostic criteria for benign paroxysmal positional vertigo (BPPV), formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society. The classification reflects current knowledge of clinical aspects and pathomechanisms of BPPV and includes both established and emerging syndromes of BPPV. It is anticipated that growing understanding of the disease will lead to further development of this classification.

Objective The aim of this work was to assess through a questionnaire the features of vertiginous episodes, accompanying symptoms, familial history, and migraine precursors in a sample of 252 subjects with a diagnosis of definite vestibular migraine. Background Migraine is a common neurological disorder characterized by episodic headaches with specific features. About two-thirds of cases run in families, and patients may refer symptoms occurring in infancy and childhood, defined as episodic syndromes that may be associated with migraine. Migraine is associated with episodic vertigo, called vestibular migraine, whose diagnosis mainly relies on clinical history showing a temporary association of symptoms. Methods In this cross-sectional multicentric study, 252 subjects were recruited in different centers; a senior specialist through a structured questionnaire assessed features of vestibular symptoms and accompanying symptoms. Results The age of onset of migraine was 23 years, while onset of vertigo was at 38 years. One hundred and eighty-four subjects reported internal vertigo (73%), while 63 subjects (25%) reported external vertigo. The duration of vertigo attacks was less than 5 minutes in 58 subjects (23%), between 6 and 60 minutes in 55 (21.8%), between 1 and 4 hours in 29 (11.5%), 5 and 24 hours in 44 (17.5%), up to 3 days in 14 (5.5%), and more than 3 days in seven (2.8%); 14 subjects (5.5%) referred attacks lasting from less than 5 minutes and up to 1 hour, nine (3.6%) referred attacks lasting from less than 5 minutes and up to 1 to 4 hours, six (2.4%) referred attacks lasting from less than 5 minutes and up to 5 to 24 hours, and five (2%) cases referred attacks lasting from less than 5 minutes and up to days. Among accompanying symptoms, patients referred the following usually occurring, in order of frequency: nausea (59.9%), photophobia (44.4%), phonophobia (38.9%), vomiting (17.8%), palpitations (11.5%), tinnitus (10.7%), fullness of the ear (8.7%), and hearing loss (4%). In total, 177 subjects referred a positive family history of migraine (70.2%), while 167 (66.3%) reported a positive family history of vertigo. In the sample, 69% of patients referred at least one of the pediatric precursors, in particular, 42.8% of subjects referred motion sickness. The age of onset of the first headache was lower in the subsample with a familial history of migraine than in the total sample. Among the pediatric precursors, benign paroxysmal vertigo - BPV, benign paroxysmal torticollis, and motion sickness were predictive of a lower age of onset of vertigo in adulthood; cyclic vomiting was predictive for vomiting during vertigo attacks in adults. Conclusions Our results may indicate that vestibular symptoms in pediatric patients may act as a predisposing factor to develop vestibular migraine at an earlier age in adulthood.

Migraine is a common neurological disorder characterized by episodic headaches with specific features, presenting familial aggregation. Migraine is associated with episodic vertigo, named Vestibular Migraine (VM) whose diagnosis mainly rely on clinical history showing a temporary association of symptoms. Some patient refers symptoms occurring in pediatric age, defined "episodic symptoms which may be associated with migraine." The aim of this cross sectional observational study was to assess migraine-related clinical features in VM subjects. For the purpose, 279 patients were recruited in different centers in Europe; data were collected by a senior neurologist or ENT specialist through a structured questionnaire. The age of onset of migraine was 21.8 ± 9. The duration of headaches was lower than 24 h in 79.1% of cases. Symptoms accompanying migrainous headaches were, in order of frequency, nausea (79.9%), phonophobia (54.5%), photophobia (53.8%), vomiting (29%), lightheadedness (21.1%). Visual or other auras were reported by 25.4% of subjects. A familial aggregation was referred by 67.4%, while migraine precursors were reported by 52.3% of subjects. Patients reporting nausea and vomiting during headaches more frequently experienced the same symptoms during vertigo. Comparing our results in VM subjects with previously published papers in migraine sufferers, our patients presented a lower duration of headaches and a higher rate of familial aggregation; moreover some common characters were observed in headache and vertigo attacks for accompanying symptoms like nausea and vomiting and clustering of attacks.

Objective The aim of this study is to evaluate the effects of an intratympanic gentamicin-dexamethasone combination on the inner ear. Materials and methods Twenty-six Wistar albino rats were divided into four groups: Group I (Control), group II (Intratympanic dexamethasone; ITD), group III (Intratympanic gentamicin; ITG), and group IV (Intratympanic gentamicin and dexamethasone; ITGD). On the first day after basal auditory brainstem response (ABR) measurements, the ITG group received 0.03 mL of intratympanic gentamicin (26.7 mg/mL). Intratympanic injection of 0.06 mL of a solution containing 13.35 mg/mL gentamicin and 2 mg/mL dexamethasone was performed in the ITGD group. 0.03 mL of physiological intratympanic serum and dexamethasone (4 mg/mL) was applied in control and ITD groups, respectively. On the 7th day, ABR measurements were repeated and vestibular functions were evaluated. On the 21th day, ABR and vestibular tests were repeated, and the animals were sacrificed for histopathological investigation. Results The ITG group's hearing thresholds deteriorated in all frequencies. The ITGD group's hearing thresholds were significantly better than the ITG group, except at 8 kHz on the 7th day and in all frequencies at the 21th day measurements. The vestibular function scores of the ITG and ITGD groups were higher than the controls. Apoptotic changes were seen in cochlea, spiral ganglion, and vestibule of the ITG group. Cochlear and vestibular structures were well preserved in the ITGD group, similar to the controls. Conclusion The ITGD combination led to a significant hearing preservation. Although in subjective vestibular tests, it seemed that vestibulotoxicity was present in both ITG and ITGD groups the histopathological investigations revealed no signs of vestibulotoxicity in the ITGD group in contrast to the ITG group. Further studies using a combination of different concentrations of gentamicin and dexamethasone are needed.

Objectives/Hypothesis The need for class I and II studies on the efficacy of liberatory maneuvers in the treatment of lateral canal benign paroxysmal positional vertigo (LC-BPPV) motivated the present double-blind randomized trial on the short-term efficacy of the Gufoni liberatory maneuver (GLM). Study Design Double-blind randomized controlled trial. Methods Seventy-two patients with unilateral LC-BPPV were recruited for a multicentric study. Patients were randomly assigned to treatment by GLM (n = 37) or sham treatment (n = 35). Subjects were followed up twice (at 1 hour and 24 hours) with the supine roll test by blinded examiners. Results At 1- and 24-hour follow-up, 75.7% and 83.8% of patients, respectively, undergoing GLM had recovered from vertigo, compared to around 10% of patients undergoing the sham maneuver (P < 0.0001). Conclusion To the best of our knowledge, this is the first class I study on the efficacy of the GLM in the treatment of LC-BPPV in both geotropic and apogeotropic forms. GLM proved highly effective compared to the sham maneuver (P < 0.0001). The present class I study of the efficacy of the GLM changes the level of recommendation of the method for treating LC-BPPV from level U to level B for the geotropic variant and from level B to level A for the apogeotropic variant of LC-BPPV. Level of Evidence 1b. Laryngoscope, 2013

Although dizziness is a common presenting symptom in general and hospital practice, its social cost is not known. We assessed the social and work life impact of dizziness on patients in two contrasting European cities, Siena and London. First, we developed the ‘Social life & Work Impact of Dizziness questionnaire’ (SWID), which was validated by administering it to 43 patients with dizziness and 45 normal controls and by correlating the results with the EQ-5D (Europe quality of life) questionnaire. The SWID and EQ-5D scores were worse in patients than controls (p < 0.001) and the two correlated significantly (r = 0.50 p < 0.001). Then two hundred consecutive patients per city attending tertiary specialised ‘dizzy patient’ clinics, one in London led by a neurologist, one in Siena led by an ear, nose and throat specialist (ENT), were investigated with SWID. Amongst the 400 patients, 27% reported changing their jobs and 21% giving up work as a result of the dizziness. Over 50% of patients felt that their efficiency at work had dropped considerably. The mean number of days off work attributed to the dizziness in the previous 6 months was 7.15 days. Social life was disrupted in 57% of all 400 patients. Factor analysis identified that detrimental effects on work, travel, social and family life combine to create a single factor accounting for much of the overall impact of their dizziness. Significant differences in some measures of handicap between London and Siena emerged, with London patients often faring worse. Reasons for these location differences include, as expected, a higher proportion of neurological patients in London than in Siena. However, factors related to city demographics and social cohesion may also modulate the impact on quality of life and working practice. Regardless of inter-city differences, these findings highlight the high social and economic impact of dizziness.

The first reports of an involvement of the lateral canal (LC) in paroxysmal positional vertigo (PPV), were published in 1985, by Luciano Cipparrone et al., from Italy and Joseph McClure from Canada. The increasing interest of otolaryngologists and neurologists has led to a progressive advance in the knowledge of this labyrinthine disorder regarding its epidemiological, physiopathological, clinical, and therapeutic aspects. According to the most recent data, LC-benign PPV accounts for 17% of all PPV patients, regardless of gender and between the two labyrinths. The LC-PPV syndrome is characterized by intense positional vertigo and direction-changing geotropic horizontal nystagmus, both caused by rotation of the head in the supine position. Less frequently, it presents with apogeotropic nystagmus. In some patients nystagmus is also detectable in the sitting position, mimicking a spontaneous nystagmus. In most cases nystagmus is caused by displaced otoconia floating in the semicircular canal. The pathological side, which must be identified for successful treatment, is usually indicated by nystagmus intensity: the more intense positional nystagmus beats toward the affected ear. In a few cases, where there is no difference in nystgmus intensity, other indicators are necessary to determine the pathological side. Vestibular neuritis and posterior fossa lesions should be considered in the differential diagnosis. Treatment of LC-PPV relies on some physical maneuvers, the objective of which is to allow the otoconial debris to exit from the LC by centrifugal inertia and/or by gravitation.

This article presents operational diagnostic criteria for benign paroxysmal positional vertigo (BPPV), formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society. The classification reflects current knowledge of clinical aspects and pathomechanisms of BPPV and includes both established and emerging syndromes of BPPV. It is anticipated that growing understanding of the disease will lead to further development of this classification.

Benign paroxysmal positional vertigo is a common labyrinthine disorder caused by a mechanic stimulation of the vestibular receptors within the semicircular canals. It is characterized by positional vertigo and positional nystagmus, both provoked by changes in the position of the head with respect to gravity. The social impact of the disease and its direct and indirect costs to healthcare systems are significant owing to impairment of daily activities and increased risk of falls. The first description of a patient with benign paroxysmal positional vertigo is from Robert Barany in 1921, but the features of the syndrome and the diagnostic maneuver were well described by Dix and Hallpike in 1952. Since then, the gradually increasing interest of otolaryngologists and neurologists has led to a progressive advance in the knowledge of this labyrinthine disorder with regard to its epidemiologic, pathophysiologic, clinical, and therapeutic aspects. Despite the often effective diagnosis and treatment of most cases of benign paroxysmal positional vertigo, the physiopathologic explanations of the disease are mainly speculative. In this chapter, we describe the epidemiologic, pathophysiologic, clinical, and therapeutic aspects of benign paroxysmal positional vertigo.

SummaryThe aim of the study was to investigate the upper respiratory tract as a site of extrapulmonary sarcoidosis. Diagnosis of sarcoidosis with upper respiratory tract involvement was performed on the basis of clinical, laboratory, radiographic and histological evidence and by excluding other granulomatous diseases in eight patients followed by the Sarcoidosis Regional Reference Centre pneumologists in collaboration with an experienced ENT specialist at Siena University. In five cases, sarcoidosis was localized in the parotid glands, in the other three subjects larynx, nasopharynx and nose were involved. In four patients parotid gland, nasopharynx and upper respiratory tract mucous membrane involvement was the only clinical manifestation at onset of the disease.Upper respiratory tract involvement should be suspected in all patients with systemic sarcoidosis and in patients with persistent upper respiratory tract symptoms of unknown cause. What a general practitioner should do as not to miss SURT is underlined. Interdisciplinary management and collaboration are of paramount importance for rapid diagnosis and to avoid the possible complications of this form.

Objective To determine the effects of transtympanic injections, with a mixture composed of gentamicin and fibrin tissue adhesive (FTA), on vestibular function of patients with intractable unilateral Meniere’s disease. Study design This was an open, prospective study. Setting and patients The study was performed at 2 tertiary referral centers. Twenty-six patients affected by “definite” unilateral Meniere’s disease, unresponsive to medical therapy for at least 6 months, were enrolled. Intervention A buffered gentamicin solution mixed with FTA was injected in the middle ear until the development of bedside vestibular hypofunction signs and/or caloric weakness in the treated ear. Main outcome measure Vestibular function was evaluated by 3 bedside vestibular tests (observation of spontaneous nystagmus, head shaking test, and head thrust test) and by a caloric test. Tests were performed on days 10 and 30 after completion of treatment. Tests were also performed 3, 6, and 12 months from completion of the gentamicin-FTA protocol. The effects of treatment were also assessed in terms of hearing levels, control of vertigo, and disability status. Results In 22 of the 26 patients, only 1 gentamicin-FTA injection was necessary to obtain 1 or more signs indicating a reduction of the vestibular function in the treated ear. Four patients needed another treatment because of the persistence of their incapacitating symptoms during the follow-up. Four patients needed more than 1 injection to obtain a vestibular hypofunction. None of the patients who received 1 or 2 injections presented hearing loss in direct temporal relationship to the treatment. Conclusions A mixture of gentamicin and fibrin glue makes it possible to considerably reduce the number of administrations in patients with intractable unilateral Meniere’s disease. Spontaneous nystagmus, post head shaking nystagmus, and a head thrust sign are the clinical signs that indicate onset or progression of unilateral vestibular hypofunction. These signs were obtained with only 1 injection in 81% of patients. EBM rating C

Paroxysmal positional vertigo (PPV) is the most common vestibular disorder observed in a dizziness unit. In 1921, Barany documented the first case. Since then many authors have defined its characteristics and pathogenetic mechanisms and suggested diagnostic and therapeutic manoeuvres. Here we outline the history of PPV and investigate its epidemiology. Two thousand two hundred and seventy PPV patients were examined over the period 1991 to 2000, at the ENT Department of Siena University. The data obtained were used to assess the incidence, prevalence, features and clinical course of the disorder.

Objective : To evaluate the effects of mechanical compression of the brain-stem in patients with vertebrobasilar dolichoectasia (VBD). Methods : In the framework of a prospective, observational study that collected clinical and laboratory data in patients with VBD, we studied 20 patients with compression of the brain-stem due to ectatic, tortuous basilar or vertebral arteries. Patients with cerebral lesions other than small lacunae in the white matter of the cerebral hemispheres were excluded from the study. Patients underwent vestibular and auditory function testing, including brain-stem auditory evoked potentials (BAEPs), blink reflex (BR), somatosensory evoked potentials (SEPs), and motor evoked potentials (MEPs). Results : Almost all of the patients complained of auditory or vestibular symptoms and none had symptoms or signs of impairment of long tracts or the facial and trigeminal nerves. The most consistent findings were BR abnormalities with prolongation of ipsilateral R1 latency in cases of compression of the pons (10/16) and prolongation of the R2 and R2c latencies with compression of the medulla oblongata (5/15). Subclinical impairment of corticospinal pathways was found in 13 out of 25 instances of compression, and this was more frequent with compression of the pons. Abnormal BAEPs or SEPs were less frequently encountered, and only in cases with compression of the pons. Conclusions : Neurovascular compression of the brain-stem, even with severe distortion, is seldom associated with overt clinical signs, whereas subclinical dysfunctions are relatively frequent. The central pathways of the BR and the corticospinal pathways are more susceptible to compression than acoustic and sensory pathways. BR, MEP and BAEP data provide a functional evaluation of the brain-stem and some cranial nerves, which is lacking in imaging studies. Functional investigations may be useful in the long-term management of these patients, since VBD may be progressive and surgical correction may be required at some stage.

The liberatory maneuver of Semont is an effective physical treatment for benign paroxysmal positional vertigo. It works because it causes otoconia to move out the posterior canal. The effectiveness of the maneuver is thought to be indicated by the appearance of a liberatory nystagmus. After the maneuver, patients are usually instructed to keep their heads erect for several days and not to lie on the pathologic side for about a week. Here we investigated the prognostic value of liberatory nystagmus and whether restrictions are necessary after treatment. Fifty-six patients with posterior canal benign paroxysmal positional vertigo underwent the Semont maneuver and were checked after 20 minutes, 24 hours, and 1 week. The patients were told that they could sleep or move as they pleased, without any particular precautions. We found that liberatory nystagmus had a high prognostic value and that it was not necessary for patients to avoid certain positions or movements after treatment.

Recurrence of vestibular neuritis (VN) is a rare event in long-term follow-up. The incidence of benign paroxysmal positional vertigo (BPPV) in VN patients represents a quite common outcome. To our knowledge, this study represents the only long-term longitudinal study on recurrence of VN and incidence of secondary BPPV in VN.To study a large number of VN patients longitudinally to identify the recurrence rate of VN and incidence of BPPV, other peripheral vestibular disorders, sudden hearing loss or Bell's palsy.This prospective cohort study assessed a VN patient-based clinic population. All patients received a complete bedside clinical examination and caloric irrigation.Long-term (range 4-6 years, mean 4.9 years) longitudinal follow-up examination of 51 VN patients demonstrated a low recurrence rate (1/51 patients, 2.0%). With recurrence, VN affected the same ear after 6 months and caused less severe symptoms. BPPV appears to be more frequent (5/51 patients, 9.8%) in VN patients than in the general population, consistently affecting the posterior canal of the same ear. BPPV occurrence after VN predominantly affects VN patients who did not fully recover from the disease. Moreover, BPPV after VN appears to be more difficult to treat than idiopathic BPPV.

Horizontal-canal paroxysmal positional vertigo (HC-PPV) is a vestibular syndrome due to canalolithiasis of the horizontal canal. The more common posterior-canal paroxysmal positional vertigo has a well defined and effective therapy, while there have been few reports on physical therapy for HC-PPV, and these have been tried in relatively few patients. We report the results of two different types of treatment of HC-PPV in 92 patients. A group of 21 untreated patients acted as a control group. One method, known as forced prolonged position (FPP), proposes liberating the affected canal by gravitation, and involves having the patient lie on the healthy side for many hours. The other method (the barbecue rotation) is a liberatory manoeuvre which proposes to expel the otoconia from the canal by rotating the patient 270 degrees around the longitudinal axis of the body in rapid steps of 90 degrees. FPP was successful in more than 70% of our patients; the barbecue rotation had slightly less successful but more immediate results. Both methods enable otoconial debris to migrate into the posterior canal. We suggest treating all patients with the two methods in succession.

Bilateral vestibular loss (BVL) is a relatively uncommon syndrome that may produce problems of balance; unsteady gait, especially in the dark; and visual disorders and/or oscillopsia associated with walking and head movements. Sometimes patients with BVL remain asymptomatic. Ototoxic drugs are the most frequently identified cause of BVL, but there are many other possible causes. The aetiology remains unknown in a large percentage of patients. In some, vascular aetiology may be suspected. Here we report 4 cases of vertebrobasilar dolichoectasia (VBD) and symptomatic BVL. In 3 subjects, hearing was preserved, but in the 4th, there was retrolabyrinthine hearing loss. In our opinion, VBD may be the cause of BVL associated or not associated with hearing loss, the reason being that since the anterior vestibular artery is small and has no anastomoses, the horizontal semicircular canal is selectively susceptible to ischemia.

The aim of this study was to assess the natural course of positional down-beating nystagmus (pDBN) and vertigo in patients with no evidence of central nervous system involvement and of presumed peripheral origin. Fifty-three patients with pDBN had a complete otoneurological examination. All subjects, apart from three (excluded from the study), showed no additional neurological signs and normal brain imaging. Patients were randomly assigned to two groups: with or without treatment with exercise. Patients were seen again after 24 h, and then weekly for up to 6 months. Forty-seven patients (94 %) showed pDBN in the straight head-hanging position and in a Dix–Hallpike position. A torsional component was detected in 17 patients (34 %). The mean latency and duration of pDBN was 4.7 ± 5 s and 40.1 ± 22 s, respectively. After 2 weeks, only 12 patients (24 %) still had pDBN and all but one patient had recovered by 1 month. Twenty patients (40 %) were diagnosed with a typical posterior canal benign paroxysmal positional vertigo (PC BPPV) before or after pDBN. This study assessed for the first time the natural course of presumed peripheral pDBN, which was characterized by a spontaneous remission in 24 patients in the first week and in 49 patients within 4 weeks. pDBN is much more common than previously suggested, with about the same frequency as lateral canal BPPV. Furthermore, the clinical characteristics of pDBN have been highlighted, as well as its possible relationship to PC BPPV.

We evaluated the incidence and characteristics of hyperventilation-induced nystagmus (HVN) in 49 patients with gadolinium-enhanced magnetic resonance imaging evidence of vestibular schwannoma and 53 patients with idiopathic unilateral sensorineural hearing loss and normal radiological findings. The sensitivity and specificity of the hyperventilation test were compared with other audio-vestibular diagnostic tests (bedside examination of eye movements, caloric test, auditory brainstem responses) in the two groups of patients. The hyperventilation test scored the highest diagnostic efficiency (sensitivity 65.3 %; specificity 98.1 %) of the four tests in the differential diagnosis of vestibular schwannoma and idiopathic unilateral sensorineural hearing loss. Small tumors with a normal caloric response or caloric paresis were associated with ipsilateral HVN and larger tumors and severe caloric deficits with contralateral HVN. These results confirm that the hyperventilation test is a useful diagnostic test for predicting vestibular schwannoma in patients with unilateral sensorineural hearing loss.

The experimental assessment of the vestibulo-ocular-reflex (VOR) gain provides an objective and quantitative measure of VOR performance which is nonetheless difficult to correlate with its efficiency in everyday living conditions. We developed the Head Impulse Testing Device (HITD) based on an inertial sensing system allowing to investigate the functional performance of the VOR by testing its gaze stabilization ability in response to head impulses at different head angular accelerations. HITD results on a population of 39 vestibular patients were compared to those of 22 controls. Overall the sensitivity of the HITD was 92% against the results of the clinical head impulse test and 83% against the clinical diagnosis, while the specificity was 58% against the clinical head impulse test and 83% against the diagnosis. The HITD appears to be a very promising tool for detecting abnormal VOR performance while providing information on the functional performance of the rotational VOR. As compared to the usual testing devices the HITD tests higher frequencies and accelerations that characterize head movements in everyday life activities and provides a functional assessment that is more likely to be related to the subject’s self-feeling.

The need for Class I and II studies on the efficacy of Semont’s liberatory maneuver (SLM) in the treatment of posterior canal benign paroxysmal positional vertigo (PC-BPPV) motivated the present double-blind randomized trial on the short-term efficacy of SLM. A total of 342 patients with unilateral PC-BPPV were recruited for a multicenter study. Patients were randomly assigned to treatment by SLM (n = 174) or sham treatment (n = 168). Subjects were followed up twice (1 and 24 h) with the Dix–Hallpike maneuver by blinded examiners. At the 1 and 24 h follow-up, 79.3 and 86.8%, respectively, of patients undergoing SLM had recovered from vertigo, compared to none of the patients undergoing the sham maneuver (p < 0.0001). Patients who manifested liberatory nystagmus at the end of SLM showed a significantly higher percentage of recovery (87.1 vs. 55.7%; p < 0.0001). To the best of our knowledge, this is the first Class I study on the efficacy of SLM. SLM proved highly effective with respect to the sham maneuver (p < 0.0001). Liberatory nystagmus was demonstrated to be a useful prognostic factor for the efficacy of treatment. The present Class I study of efficacy of SLM changes the level of recommendation of the maneuver for treating PC-BPPV from level C to level B.

This study describes a patient with lateral medullary ischemia (LMI) presenting with persistent hiccups followed by vertigo with horizontal head-shaking-induced contralesional nystagmus (HSN) and discusses pertinent pathophysiology. A 65-year-old man presented with persistent hiccups and disabling spells of vertigo, lasting 30 seconds that became much more frequent and associated with lateropulsion to the right. A strong left beating HSN was evident. Magnetic resonance imaging and angiography, and intra-arterial cerebral digital subtracted angiography showed subacute ischemic lesions in the right lateral medulla and ipsilateral inferior cerebellar hemisphere, and two tight stenoses of the V1 and V4 segments of the right vertebral artery. Patient was treated by intravenous heparin and oral clopidogrel. After 48 hours, hiccups disappeared. One month later, vertigo spells were less frequent but still disabling. Endovascular stenting of the right vertebral artery stenoses was then performed. In the subsequent four years, the patient had no further episodes of hiccups or vertigo. Less intense HSN persisted. Hiccups followed by vertigo, lateropulsion, and HSN had been the clinical presentation of LMI and cerebellar ischemia, without other major neurologic or ocular motor findings. This unusual clinical variant of LMI could mimic a more benign labyrinthine lesion, and possibly leading to a dangerously delayed treatment.

Publisher Summary This chapter describes benign paroxysmal positional vertigo (BPPV) as a mechanical labyrinthine disorder characterized by positional vertigo and paroxysmal positional nystagmus (PPN), both caused by the changes of the position of the head with respect to gravity. The increasing interest of otolaryngologists and neurologists has led to a progressive advance in the knowledge of this labyrinthine disorder regarding its epidemiological, and clinical and therapeutic aspects. The chapter discusses the symptoms of BPPV that are often stereotyped and a reliable diagnosis is usually possible on the basis of the patient's description. The episodes of vertigo are always triggered by certain head movements. BPPV is recurrent, since attacks usually occur whenever a critical movement is performed, but attacks generally recur over a limited period of time that may be days, weeks, or exceptionally months. The chapter reviews that the aim of physical therapy is to eliminate the episodes of positional vertigo by dislodging the otoconial debris from the semicircular canals. The special movements, and the positions of the head and body are used to trigger a series of clinical events that are consistent with the canalolithiasis hypothesis. Therapies for posterior and lateral canal BPPV have been validated. On the other hand, specific diagnostic criteria and effective treatment for the anterior canal variant of BPPV are still elusive. Surgery and medications play a minor role in BPPV.

BACKGROUND: Converging evidence indicates that action observation and action-related sounds activate cross-modally the human motor system. Since olfaction, the most ancestral sense, may have behavioural consequences on human activities, we causally investigated by transcranial magnetic stimulation (TMS) whether food odour could additionally facilitate the human motor system during the observation of grasping objects with alimentary valence, and the degree of specificity of these effects. METHODOLOGY/PRINCIPAL FINDINGS: In a repeated-measure block design, carried out on 24 healthy individuals participating to three different experiments, we show that sniffing alimentary odorants immediately increases the motor potentials evoked in hand muscles by TMS of the motor cortex. This effect was odorant-specific and was absent when subjects were presented with odorants including a potentially noxious trigeminal component. The smell-induced corticospinal facilitation of hand muscles during observation of grasping was an additive effect which superimposed to that induced by the mere observation of grasping actions for food or non-food objects. The odour-induced motor facilitation took place only in case of congruence between the sniffed odour and the observed grasped food, and specifically involved the muscle acting as prime mover for hand/fingers shaping in the observed action. CONCLUSIONS/SIGNIFICANCE: Complex olfactory cross-modal effects on the human corticospinal system are physiologically demonstrable. They are odorant-specific and, depending on the experimental context, muscle- and action-specific as well. This finding implies potential new diagnostic and rehabilitative applications.

A 62-year-old woman with relapsing-remitting multiple sclerosis suddenly complained of diplopia associated with bilateral adduction impairment, nystagmus of the abducting eye bilaterally, and sparing of abduction, convergence, and vertical eye movements, consistent with bilateral internuclear ophthalmoplegia. Within 1 week, she had developed a complete horizontal gaze paralysis even with the oculocephalic maneuver. Vertical saccades were slow and convergence was preserved. There was a right lower motor neuron seventh cranial nerve palsy. Brain MRI showed a new enhancing lesion involving the pontine tegmentum. Clinical and MRI follow-up showed recovery after 6 months. The slowing of vertical saccades may have been due to spread of the demyelinating lesion to the adjacent paramedian pontine reticular formation, which contains omnipause neurons lying in the raphe interpositus nucleus thought to inhibit excitatory burst neurons for horizontal and vertical saccades. Our patient verifies the fact that vertical saccadic abnormalities may occur from a lesion apparently confined to the pons.

Vertigo in children is relatively under examined in the literature. Among its causes, vestibular neuritis (VN) represents only 2% of cases, with its etiology remaining unknown. We report for the first time a 4-year-old boy with vestibular neuritis and serological results compatible with adenoviral infection. Serological diagnosis was performed on the basis of a rise and consequent normalization of complement fixation (CF) titers of the plasma antibodies. Although we were not able to detect exactly when the infection started, we were able to detect an increased level of adenovirus antibodies by CF titers, followed by a decrease (i.e. 1/16, then 1/8, then1/4) during the recovery. This is typical of a resolving infection. Furthermore, that this increase in antibodies was specific to an adenovirus infection was suggested by the observation that we did not detect increases in antibodies to other common viruses (i.e. herpes simplex and zoster viruses, Epstein-Barr virus, cytomegalovirus, influenza and parainfluenza viruses). This allows us to exclude the chance of nonspecific antibody activation. We concluded that, although our data do not formally demonstrate an involvement of adenovirus in VN, they suggest such an involvement. This may be of interest, given that a viral etiology for VN has been proposed but not definitively proven.

We compared bedside tests of vestibulo-ocular function (head thrust and head heave signs) with caloric testing results in 68 patients with acute vestibular neuritis seen at onset and in follow-up for one year. The head thrust and head heave signs each were strong predictors of a decreased probability of recovery, and if both were present, there was a trend for a slower recovery and a further decrease in the probability of recovery. If the head thrust sign was absent, recovery was assured. Our results suggest that careful bedside testing of semicircular canal (head thrust maneuver) and otolith (head heave maneuver) function provides useful information for predicting prognosis in patients with acute vestibular neuritis.

The present study compares the efficacy and safety of betahistine dihydrochloride to that of a placebo in recurrent vertigo resulting from Meniere's disease (MD) or in paroxysmal positional vertigo (PPV) of probable vascular origin. The design was double-blind, multicentre and parallel-group randomised. Eleven Italian centres enrolled 144 patients: 75 of the patients were treated with betahistine (41 MD/34 PPV) and 69 with placebos (40 MD/29 PPV). The betahistine dosage was 16 mg twice per day for 3 months. Compared to the placebo, betahistine had a significant effect on the frequency, intensity and duration of vertigo attacks. Associated symptoms and the quality of life also were significantly improved by betahistine. Both the physician's judgement and the patient's opinion on the efficacy and acceptability of the treatment were in agreement as to the superiority of betahistine. The effective and safe profile of betahistine in the treatment of vertigo due to peripheral vestibular disorders was confirmed.

It has been postulated that bilateral sensorineural hearing loss (SNHL) may be the result of an ongoing autoimmune process against the inner ear and a pattern of progressive bilateral SNHL linked to an autoimmune inner ear disorder has been reported. Various attempts have been made to develop an assay to confirm the diagnosis of autoimmune inner ear disease. In this study we used a Western blot assay to determine the presence of IgG antibodies directed against a PO antigen (30 kDa) of the guinea pig in the sera of patients affected by sudden loss of vestibular function (SLVF). Ten patients affected by vestibular neuritis were enrolled: eight with unilateral vestibular loss and two with sequential bilateral impairment. We also tested nine patients with sudden unilateral hearing loss, five with benign paroxysmal positional vertigo and six normal subjects. In the present study only one patient, a woman affected by bilateral vestibular impairment, had IgG antibodies against the PO protein. Our results indicate either that the antigen PO is not a valid marker for autoimmune unilateral SLVF or that our patients did not have an immunological basis for their disease. However, we can suggest that bilateral impairment of vestibular function and bilateral progressive SNHL are more likely to be immune-mediated disorders and that PO could be a valid marker for these diseases. As bilateral vestibular neuritis is an uncommon disease, a multicentre study is required to confirm our suggestions.

Benign paroxysmal positional vertigo of the horizontal semicircular canal (HC-BPPV) is a well-defined syndrome characterized by direction-changing horizontal positional nystagmus. We report the clinical features of 5 patients who illustrate the possible variables of the syndrome. In most cases, nystagmus is geotropic and more intense when the pathological ear is lowermost; less often the syndrome presents with apogeotropic nystagmus that is more intense when the affected ear is uppermost. The nystagmus pattern may vary in time in the same patient, changing from apogeotropic to geotropic even in observations at short intervals. In some patients, the features indicate involvement of more than one canal, either simultaneously or in succession. It is sustained that the clinical findings can be explained by movement of endolymph caused by displacement of otoconia in the semicircular canals and that variants are due to different positions of the otoconia within the canals.

To determine whether the use of 4 bedside tests (head-impulse, head-heave, head-shake, and vibration tests) can be as effective as the caloric test, a widely accepted standard, in the diagnosis and prediction of the time to recovery from vestibular neuritis.Inception cohort (1-year follow-up), criterion standard study.Primary referral center.All patients had acute vertigo, and those having a diagnosis of vestibular neuritis were eligible for inclusion in the study. Sixty-eight patients (43 men and 25 women; mean age, 54.9 years) met this criterion, and 53 of them (77.9%) completed the study.Spontaneous head-shaking and vibration-induced nystagmus elicited with a battery-powered device were tested wearing Frenzel goggles. The head-impulse and head-heave tests were performed manually. Caloric irrigation was administered with hot, cold, and ice water.At baseline, more than half of the patients exhibited positive signs with all 4 tests and all had caloric paralysis or paresis. Signs with the head-impulse and head-heave tests correlated highly (odds ratio, 24.9; P.001), as did those with the head-shake and vibration tests (odds ratio, 22.8; P.001). Patients with a positive sign with the head-impulse or vibration test were 70% less likely to recover than were those with a negative sign. Head-impulse (hazard ratio, 0.08; P = .002) and head-shake (hazard ratio, 0.23; P = .01) test results were associated with the outcome of the caloric test.Careful bedside examination of patients with vestibular neuritis has both diagnostic value in the short term and prognostic value in the long term.

We report two cases of non periodic alternating nystagmus, one of vascular origin (ischemia of the vertebrobasilar territory) and a second of traumatic origin (whiplash injury) with otoneurological signs, typical of lesions in posterior cranial fossa and in particular of vestibulum-cerebellum and brainstem: gaze paretic nystagmus, rebound nystagmus, saccadic dysmetria, vestibular hyperreflexia and impaired visual suppression test. In one case it was possible to give baclofen therapy, which yielded positive results. Suspension of drug administration resulted in the worsening of clinical signs. The mechanism of action of the drug will be discussed.

We conducted a study of 60 patients with different nasal pathologies who complained of nasal obstruction. Our goal was to evaluate the reliability of rhinomanometry, acoustic rhinometry, and the measurement of mucociliary transport time in helping make the diagnosis of nasal pathologies. We also sought to discover whether there is a correlation between the findings of these objective tests and the results of patients’ own subjective assessments of nasal obstruction. We found that acoustic rhinometry was more specific and more sensitive than rhinomanometry in diagnosing rhinopathies inpatients with structural anomalies. Symptom scores as rated by patients on the visual analog scale frequently did not correlate with objective measures, as patients often overestimated the severity of their obstruction. However, for a few patients, there was a correlation between symptom scores and mucociliary transport times.