Otoconia and otolithic membrane fragments within the posterior semicircular canal in benign paroxysmal positional vertigo

Difference in the immediate effect on positional nystagmus for head positions with interval time during Epley maneuver: a randomized trial

OBJECTIVES

The Epley maneuver (EM) shows immediate effect, wherein disappearance of positional nystagmus occurs soon after the EM. Our previous study showed that setting interval times during the EM reduced the immediate effect. The purpose of this study is to identify the head position for which interval time reduces the immediate effect.

METHODS

Fifty-one patients with posterior canal type of benign paroxysmal positional vertigo (BPPV) were randomly assigned to the following three groups: 10 min interval time set at the first head position of the EM in group A, at the third head position in group B, and at the fourth head position in group C. The primary outcome measure (POＭ) was the ratio of maximum slow-phase eye velocity of positional nystagmus soon after the EM, compared with that measured before the EM. A large ratio value indicates a poor immediate effect of the EM.

RESULTS

The POＭ in group A (0.07) was smallest (B: 0.36, C: 0.49) (p < 0.001).

DISCUSSION

The interval times at the third and fourth head positions reduced the immediate effect of the EM. Our previous study showed that the effect of BPPV fatigue is continued by maintaining the first head position of the EM. BPPV fatigue constitutes fatigability of positional nystagmus with repeated performance of the Dix-Hallpike test. Our findings may be interpreted in accordance with the theory that the immediate effect of the EM is BPPV fatigue itself, because we observed that the effect of BPPV fatigue is strongest in group A.

Numerical Simulations of the Epley Maneuver With Clinical Implications

OBJECTIVES

Canalith repositioning procedures to treat benign paroxysmal positional vertigo are often applied following standardized criteria, without considering the possible anatomical singularities of the membranous labyrinth for each individual. As a result, certain patients may become refractory to the treatment due to significant deviations from the ideal membranous labyrinth, that was considered when the maneuvers were designed. This study aims to understand the dynamics of the endolymphatic fluid and otoconia, within the membranous labyrinth geometry, which may contribute to the ineffectiveness of the Epley maneuver. Simultaneously, the study seeks to explore methods to avoid or reduce treatment failure.

DESIGN

We conducted a study on the Epley maneuver using numerical simulations based on a three-dimensional medical image reconstruction of the human left membranous labyrinth. A high-quality micro-computed tomography of a human temporal bone specimen was utilized for the image reconstruction, and a mathematical model for the endolymphatic fluid was developed and coupled with a spherical particle model representing otoconia inside the fluid. This allowed us to measure the position and time of each particle throughout all the steps of the maneuver, using equations that describe the physics behind benign paroxysmal positional vertigo.

RESULTS

Numerical simulations of the standard Epley maneuver applied to this membranous labyrinth model yielded unsatisfactory results, as otoconia do not reach the frontside of the utricle, which in this study is used as the measure of success. The resting times between subsequent steps indicated that longer intervals are required for smaller otoconia. Using different angles of rotation can prevent otoconia from entering the superior semicircular canal or the posterior ampulla. Steps 3, 4, and 5 exhibited a heightened susceptibility to failure, as otoconia could be accidentally displaced into these regions.

CONCLUSIONS

We demonstrate that modifying the Epley maneuver based on the numerical results obtained in the membranous labyrinth of the human specimen under study can have a significant effect on the success or failure of the treatment. The use of numerical simulations appears to be a useful tool for future canalith repositioning procedures that aim to personalize the treatment by modifying the rotation planes currently defined as the standard criteria.

Increased prevalence of peripheral vestibular disorder among patients with Fabry disease

BACKGROUND

Although peripheral vestibular disorder is a non-fatal complication of Fabry disease, fatalities have been reported in some case reports and case series. To date, no studies have examined the relative risk of peripheral vestibular disorder in patients with Fabry disease compared to the general population without the condition. Due to the high prevalence of Fabry disease in East Asia and the potential shared pathogenic pathways between Fabry disease and vasculopathy, we conducted a study using a nationwide population-based dataset to compare the prevalence of peripheral vestibular disorder between patients with Fabry disease and matched comparison patients.

METHODS

Data was sourced from Taiwan's Longitudinal Health Insurance Database 2010. this study consists of 11,668 sampled patients, 2917 study patients with Fabry disease and 8751 propensity-score-matching comparison patients. We conducted multiple logistic regression analysis to study the association between peripheral vestibular disorder and Fabry disease.

RESULTS

The study identified notable differences in the prevalence of various vestibular disorders between the study and comparison groups. Specifically, there was a 7.2% increased prevalence of peripheral vestibular disorder in the study group (28.3%) compared to the comparison group (20.9%), Meniere's disease (5.4% vs. 3.7%), benign paroxysmal positional vertigo (5.1% vs. 3.3%), and other/ unspecified peripheral vestibular dizziness (15.6% vs. 11.8%) (all p < 0.001). The odds ratios for PVD, MD, BPPV, and other PVD were 1.44 (95% CI = 1.29-1.60), 1.50 (95% CI = 1.23-1.83), 1.59 (95% CI = 1.30-1.95), and 1.40 (95% CI = 1.24-1.58), respectively, among the Fabry disease group relative to the comparison group after adjusting for age, monthly income, geographic location, urbanization level, hyperlipidemia, diabetes, coronary heart disease, and hypertension.

CONCLUSION

This study found that patients with Fabry disease had increased prevalence of peripheral vestibular disorder.

Benign paroxysmal positional vertigo without dizziness is common in people presenting to falls clinics

PURPOSE

To determine the prevalence of benign paroxysmal positional vertigo without dizziness, a treatable falls risk factor in people attending outpatient falls clinics.

METHODS

Over 6 years, 618 people at risk of falls attending 2 falls clinics were assessed for benign paroxysmal positional vertigo, whether dizzy or non dizzy. Data regarding demographics, canal location of positive tests and comorbidities were collected from medical records.

RESULTS

Thirty-nine percent (238) of people with falls risk tested positive for benign paroxysmal positional vertigo; 62 (26%) or 1 in 4 of those testing positive were not dizzy. Thirty-nine of 104 (38%) testing positive for single canal benign paroxysmal positional vertigo and twenty-four of 134 (18%) testing positive for multiple canal benign paroxysmal positional vertigo were not dizzy. Comorbidities were common for all with falls risk but did not differentiate for benign paroxysmal positional vertigo on testing.

CONCLUSIONS

Benign paroxysmal positional vertigo is common in people attending falls clinics and contributes to falls risk. Dizziness is common in BPPV though 26% or 1 in 4 people testing positive were not dizzy and would be missed without mandatory testing. Testing should also include all semicircular canals as multiple-canal involvement was high.

Posterior Canal Fibrosis: A Case Series

OBJECTIVE

To establish a case series where loss of magnetic resonance fluid signal intensity in the posterior semicircular canal (SCC) corresponded with a functional deficit on clinical and video head impulse testing, and most likely a result of canal fibrosis or obstruction.

PATIENTS

Three patients with an magnetic resonance imaging (MRI) showing loss of T2-weighted signal intensity in their posterior SCC corresponding to a vestibular weakness in that canal.

INTERVENTIONS

All patients underwent a comprehensive neuro-otologic examination. Vestibulo-ocular reflex was evaluated using clinical head impulse testing (cHIT) and quantified with video head impulse testing. MRI for all patients was obtained using clinical protocols for gadolinium-enhanced MRI of the internal auditory canal on 1.5 or 3 T scanners, which all included high-resolution, heavily T2-weighted imaging of the membranous labyrinth.

MAIN OUTCOME MEASURE

Correlation of MRI findings with vestibular weakness in the corresponding posterior SCC.

RESULTS

Subject 1 showed abnormal vHIT in the left lateral and left posterior SCCs. MRI showed loss of T2 signal intensity of the entire left posterior SCC as well as in the posterior limb of the superior SCC. Subject 2 showed isolated loss of function (cHIT) and low gain with catch-up saccade (vHIT) of the left posterior SCC. MRI showed loss of T2 signal intensity of the superior portion of the left posterior SCC, as well as in the posterior limb of the superior SCC. Subject 3 showed catch-up saccades of the left posterior SCC on cHIT and vHIT and loss of T2 signal intensity of the entire left posterior SCC and partial loss of bilateral lateral SCC on MRI.

CONCLUSIONS

In this case series, loss of posterior SCC function correlated with vestibular function testing and high-resolution, T2-weighted MRI findings, perhaps related to fibrosis of the posterior SCC.

Benign paroxysmal positional vertigo and asymmetric hearing loss: is the worst hearing ear likely to suffer from otoconial displacement?

PURPOSE

Benign paroxysmal positional vertigo (BPPV) may be found in patients complaining of hearing disorders. The aim of our investigation was to describe audiological findings in BPPV patients, focusing on subjects with asymmetric hearing loss (AHL), to better understand whether otoconial displacement may occur preferentially in the worst hearing ear.

METHODS

A prospective study was performed on 112 BPPV patients. We divided the sample into subjects who suffered from AHL (G1) and patients with did not (G2). Data regarding vestibular symptoms, tinnitus, migraine, antivertigo drug therapy, and vascular risk factors were collected.

RESULTS

Out of 30 AHL subjects, 83.33% of them were affected by sensorineural hearing loss (SNHL) in at least one ear, with a significant difference in the distribution of hearing loss type between groups (p = 0.0006). In 70% of cases, the ear affected by BPPV was the one with the worst hearing threshold (p = 0.02); threshold asymmetry predicted BPPV in the worst hearing ear (p = 0.03). The predictability depended neither on the hearing threshold gap between ears nor the severity of the hearing threshold in the worst ear (p > 0.05). No differences in vascular risk factors between groups were observed (p > 0.05). We evidenced a moderate correlation between age and hearing threshold (ρ = 0.43). Age did not result a predictive factor for residual dizziness or BPPV in the worst ear (p > 0.05).

CONCLUSIONS

Our study supports the likelihood of an otoconial displacement in the worse hearing ear in BPPV patients. Clinicians should start testing the worst hearing ear when managing AHL patients with suspected BPPV.

Neurological update: neuro-otology 2023

Much has changed since our last review of recent advances in neuro-otology 7 years ago. Unfortunately there are still not many practising neuro-otologists, so that most patients with vestibular problems need, in the first instance, to be evaluated and treated by neurologists whose special expertise is not neuro-otology. The areas we consider here are mostly those that almost any neurologist should be able to start managing: acute spontaneous vertigo in the Emergency Room-is it vestibular neuritis or posterior circulation stroke; recurrent spontaneous vertigo in the office-is it vestibular migraine or Meniere's disease and the most common vestibular problem of all-benign positional vertigo. Finally we consider the future: long-term vestibular monitoring and the impact of machine learning on vestibular diagnosis.

Significance of subtype-determining questionnaire in efficient diagnosis and treatment of BPPV

BACKGROUND

Rapid recognition of benign paroxysmal positional vertigo (BPPV) matters in many ways, questionnaires evolve as a new alternative for diagnosis. A subtype-determining questionnaire is a more advanced but rarely studied type.

OBJECTIVE

To explore the practicability of a subtype-determining questionnaire in facilitating diagnosis and treatment of BPPV.

METHODS

A BPPV subtype-determining questionnaire was applied to vertiginous patients. All patients underwent the positional test, performed by one technician, who was either informed or uninformed about questionnaire results randomly. In the informed group, the technician checked the canal indicated by the questionnaire straightforwardly; in the uninformed group, she performed the conventional positional test. Diagnostic parameters of the questionnaire and disparities between the 2 groups were investigated.

RESULTS

The accuracy, sensitivity, specificity of question 1-3 for diagnosing BPPV is 74.4%, 90.9%, 66.6% respectively. Question 4 shows an accuracy of 80.7% in determining BPPV subtype, question 5 yields an accuracy of 78.7% in ascertaining the affected side, question 6 exhibits an accuracy of 87.2% in deciding canalithiasis or cupulolithiasis. Both examination and treatment time were shorter in the informed group (p < .05).

CONCLUSION

This subtype-determining questionnaire has appealing diagnostic ability. It provides valuable information that's conducive to fast diagnosis and efficient treatment of BPPV.

Subjective visual vertical deviation in patients with early-onset direction-changing horizontal positional nystagmus

OBJECTIVE

Otolithic dysfunction is investigated in cases of direction-changing horizontal positional nystagmus (DCHPN) due to peripheral vestibular disorders.

METHODS

The static-subjective visual vertical (S-SVV) was conducted in DCHPN cases within 48 h after onset.

RESULTS

The absolute values of S-SVV deviations of patients with Light cupula and lateral canal-benign paroxysmal positional vertigo-cupulolithiasis (L-BPPV-Cup) were significantly different from those of healthy subjects (p < 0.001, p < 0.05, respectively), whereas there were no significant differences in those of patients with L-BPPV-Canalolithiasis-geotropic (L-BPPV-Can-g) or L-BPPV-Can-ageotropic (L-BPPV-Can-a) versus healthy subjects. Significant differences were found in S-SVV (+: deviation to the affected side, -: deviation to the unaffected side) between patients with Light cupula and those with L-BPPV-Can-g, L-BPPV-Can-a and L-BPPV-Cup (p < 0.01, p < 0.05, and p < 0.001, respectively), as well as between those with L-BPPV-Can-g and L-BPPV-Cup (p < 0.01). The S-SVV in patients with Light cupula, L-BPPV-Can-g, and L-BPPV-Can-a deviated more to the affected side, whereas that in patients with L-BPPV-Cup deviated more to the unaffected side.

CONCLUSION

Mild otolithic dysfunctions were found in patients with DCHPN due to the presence of peripheral vestibular disorders within 48 h after onset. The extent of otolithic (utricular) disorders in patients with DCHPN is estimated in decreasing order as follows: Light cupula > L-BPPV-Cup > L-BPPV-Can-g and L-BPPV-Can-a. Many patients with L-BPPV-Cup likely suffer from disorders of the pars externa of the utricular macula, whereas many patients with L-BPPV-Can-g likely suffer from disorders of the pars interna of the utricular macula. L-BPPV-Can-a and L-BPPV-Can-g must be induced by a common mild utricular disorder.

Cupulolithiasis: A Critical Reappraisal

Objective

To review the history and pathophysiologic theories for cupulolithiasis and canalith jam in benign paroxysmal positional vertigo.

Data Sources

PubMed, Google Scholar.

Review Methods

Three PubMed and Google Scholar searches were performed, keywords: "cupulolithiasis," "apogeotropic [and] benign," and "canalith jam," resulting in 187 unique full-text articles in English or with English translation. Figures-Labyrinthine photographs were obtained of fresh utricles, ampullae, and cupulae of a 37-day-old mouse.

Conclusions

Freely moving otoconial masses explain most cases (>98%) of benign paroxysmal positional vertigo. Evidence that otoconia adhere strongly or persistently to the cupula is lacking. Apogeotropic nystagmus in the horizontal canal form is often attributed to cupulolithiasis; however, periampullary canalithiasis explains self-limited nystagmus, and reversible canalith jam explains prolonged apogeotropic nystagmus. Treatment-resistant cases can be explained by entrapment of particles in the canals or ampullae, but persistent adherence to the cupula remains theoretical.

Implications for Practice

Apogeotropic nystagmus is usually due to freely moving particles and should not be used in studies of horizontal canal benign paroxysmal positional vertigo as the sole method to define entrapment or cupulolithiasis. Caloric testing and imaging may help differentiate jam from cupulolithiasis. Treatment for apogeotropic benign paroxysmal positional vertigo should include maneuvers that rotate the head through 270° to fully clear the canal of mobile particles, using mastoid vibration or head shaking if entrapment is suspected. Canal plugging can be used for treatment failures.

Association between otolin-1 and benign paroxysmal positional vertigo: A meta-analysis

Background

There is increasing research on the potential of inner ear proteins as serum biomarkers for the diagnosis and prognosis of various inner ear diseases. Among them, benign paroxysmal positional vertigo (BPPV) is the most common vestibular disease. Notably, otolin-1, an inner ear-specific protein, is detectable in the serum of most patients with BPPV patients. Therefore, we found a need to conduct this meta-analysis to determine the relationship between otolin-1 in serum and BPPV.

Methods

This meta-analysis was conducted by searching PubMed, EMBASE, Cochrane Library, Google Scholar, and China Network Knowledge Infrastructure databases for the eligible original studies in Chinese or English published between January 2010 and February 2022. Data were collected and pooled by using the mean differences (MDs) corresponding to 95% confidence intervals (CIs). Heterogeneity among these studies was assessed by using I² statistics and the adopted fixed or random-effect mode thereafter. Egger's and Begg's tests were also used to assess the publication bias.

Results

This meta-analysis included six articles with a total of 585 participants. Serum otolin-1 levels were remarkably increased in patients with BPPV as compared to that in healthy controls (MD: 165.38, 95% CI: 110.13-220.64, p < 0.00001). However, Egger's and Begg's tests have indicated no publication bias, and the results were reliable based on the sensitivity analysis.

Conclusion

This meta-analysis indicated that there is a higher serum level of otolin-1 in patients with BPPV than in healthy controls. Therefore, otolin-1 may serve as a biomarker for the onset of BPPV.

Canal switch in benign paroxysmal positional vertigo: Clinical characteristics and possible mechanisms

BACKGROUND

Canal switch-benign paroxysmal positional vertigo (CS-BPPV) refers to the phenomenon in which otolith particles move from one canal to another (on the ipsilateral side) during or after canalith repositioning procedure (CRP). However, the clinical characteristics of CS-BPPV and the underlying pathological mechanisms remain unclear. In this study, we investigated the incidence of canal switch (CS) for the different semicircular canals in benign paroxysmal positional vertigo (BPPV), examined nystagmus characteristics, and explored the underlying mechanisms.

METHODS

Clinical data for 1,099 patients with single-canal BPPV were collected and retrospectively analyzed. The incidences of CS in the different types of BPPV were analyzed. Patients were divided into CS-BPPV and non-CS (NCS)-BPPV groups according to whether they exhibited CS after CRP. The baseline characteristics and nystagmus characteristics of patients were compared between the two groups.

RESULTS

Patients with BPPV who developed or did not develop CS accounted for 4.6% (51/1,099) and 95.4% (1,048/1,099), respectively, of the patients included in the study. There were no statistically significant differences between the two groups in terms of sex, age, side of the canals involved, hypertension, or diabetes. CS was observed in 3.7% (25/677) of patients with PC-BPPV, including conversion between posterior canal (PC) and horizontal canal (HC) (1.6%, 11/677), and between PC and anterior canal (AC) (2.1%, 14/677). CS was observed in 5.2% (17/327) of patients with HC-BPPV, including from HC to PC (4.3%, 14/327), and from HC to AC (0.9%, 3/327). CS was found in 9.5% (9/95) of patients with AC-BPPV, including from AC to PC (8.4%, 8/95), and from AC to HC (1.1%, 1/95). The intensity of nystagmus was significantly greater in the CS-BPPV group compared with that in the NCS-BPPV group [24.00 (11-39) vs. 12.00 (7-24), P < 0.001]. Furthermore, the incidence of direction-reversing nystagmus was significantly higher in the CS-BPPV group than in the NCS-BPPV group [31.4% (16/51) vs. 4.3% (45/1,048), P < 0.001].

CONCLUSIONS

CS in BPPV is uncommon. Patients with AC-BPPV are more likely to develop CS, followed by patients with HC-BPPV and PC-BPPV. The occurrence of CS-BPPV may be related to the anatomical structure of the semicircular canals. When the canals contain large/heavy accumulations of otolith particles, CS may be more common during re-examination after CRP.

Bilateral Dysfunction of Otolith Pathway in Patients With Unilateral Idiopathic BPPV Detected by ACS-VEMPs

Objective

To observe the functional status of the otolith pathway in patients with unilateral idiopathic benign paroxysmal positional vertigo (BPPV) by combining air-conducted sound elicited cervical vestibular-evoked myogenic potential (ACS-cVEMP) and ocular vestibular-evoked myogenic potential (ACS-oVEMP).

Methods

One hundred and eighty patients with BPPV were recruited for conventional cVEMP and oVEMP tests. The abnormal rates of VEMPs were compared between BPPV patients and control participants.

Results

The abnormal rates of cVEMP and oVEMP in BPPV patients were 46.7% (84/180) and 57.2% (103/180) in affected ears, respectively, and 45.0% (81/180) and 56.7% (102/180) in unaffected ears, respectively; both were significantly higher than the abnormal rates of cVEMP and oVEMP in normal control ears. Compared with normal subjects, the cVEMP response rate was lower in affected and unaffected ears in BPPV patients. The abnormal rates of cVEMP and oVEMP were 48.1% (76/158) and 57.6% (91/158) in patients with posterior semicircular canal BPPV, and 36.4% (8/22) and 54.5% (12/22) in lateral semicircular canal BPPV. There was no significant difference in VEMP abnormalities between posterior semicircular canal BPPV and lateral semicircular canal BPPV.

Conclusion

The prevalence of abnormal cVEMPs and oVEMPs in both affected and unaffected ears of patients with BPPV was significantly higher than that observed in the control group. The pathological mechanism of unilateral idiopathic BPPV may be associated with bilateral degeneration of otolith pathways.

Diagnostic Positional Tests and Therapeutic Maneuvers in the Management of Benign Paroxysmal Positional Vertigo

Benign Paroxysmal Positional Vertigo (BPPV), the most common vestibular disorder characterized by recurrent, brief episodes of vertigo, is attributed to the presence of otoconia in the semicircular canals. Two mechanisms contribute to its cause-canalolithiasis (otoconia freely mobile in the semicircular canal) and cupulolithiasis (otoconia adherent to the cupula). Posterior semicircular canal is the most common canal involved. Although the occurrence of BPPV in lateral and superior semicircular canal is rare, with the advancement in diagnostic techniques, their incidence is being reported in the past few years. Various diagnostic tests and therapeutic maneuvers have been described in the management of BPPV. The present report is a comprehensive review of the tests and maneuvers for BPPV written as a guide intended to help the clinicians in the accurate diagnosis and application of a canal-specific treatment maneuver for BPPV. A simplified algorithmic approach ("The Bangalore BPPV Algorithm") for the management of BPPV is described.

Advances in otolith-related protein research

Otoliths are biological crystals formed by a layer of calcium carbonate crystal that adhere to the ciliary surface of the utricular and saccular receptors in the vestibule of all vertebrates inner ear, enabling the utricle and saccule to better perceive the changes in linear and gravitational acceleration. However, the molecular etiology of otolith related diseases is still unclear. In this review, we have summarized the recent findings and provided an overview of the proteins that play important roles in otolith formation and maintenance (Otoconin-90, Otolin-1, Otolith Matrix Protein-1, Cochlin, Otogelin, α-Tectorin, β-Tectorin, Otopetrin-1, and Otopetrin-2, PMCA2, etc.), providing new insight for the prevention and management of benign paroxysmal positional vertigo (BPPV) with basis for otolith-related proteins as potential biomarkers of vestibular disease.

Immediate repeated testing ( IRT ) for BPPV : A cost‐effective examination

Objective

To show that a negative Dix‐Hallpike test or Pagnini‐McClure test may convert into positive after head shaking in cases of semicircular canalith jam.

Methods

This is a retrospective study, where 768 cases of BPPV were studied of which 36 were found to have canalith jam.

Results

Thirty‐six patients (4.7%) presented with canalith jam; 4.8% of posterior canal BPPV and 3.7% of lateral canal BPPV were attributed to canalith jam.

Conclusion

Immediate repeated testing for BPPV allows us to identify undiagnosed cases of BPPV where canalith jam has occurred. It is a cost‐effective technique that provides benefits for clinicians, patients, and the healthcare system.

Magnetic resonance imaging of the endolymphatic space in patients with benign paroxysmal positional vertigo: volume ratio and distribution rate of the endolymphatic space

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disease. It is characterised by sudden onset short lived vertigo triggered by sudden changes in head position relative to gravity.

AIMS/OBJECTIVES

We aimed to perform a quantitative volumetric analysis of the inner ear endolymphatic space in patients with BPPV.

MATERIAL AND METHODS

This study included 67 patients with BPPV and 50 control subjects (CS). The endolymphatic space/total fluid space volume ratio (%) and the distribution rate of the inner ear components in the endolymphatic space (%) were measured using three-dimensional magnetic resonance imaging.

RESULTS

Differences in the endolymphatic space/total fluid space volume ratio of the inner ear, cochlea, vestibule, and semi-circular canals (SCCs) between the CS and BPPV groups were not significant. The endolymphatic space distribution rate of the vestibule in the BPPV group was significantly lower than that in the CS group, and the endolymphatic space distribution rate of SCCs in the BPPV group was significantly higher than that in the CS group.

CONCLUSIONS AND SIGNIFICANCE

Extended endolymphatic space in patients with BPPV did not exist. The otoconia released from the damaged utricles were considered to move with the endolymphatic flow toward SCCs.

Vestibular Test Results in Patients With Horizontal Canal Benign Paroxysmal Positional Vertigo

Introduction

While the mechanism of posterior canal benign paroxysmal positional vertigo (BPPV) is widely accepted as canalolithiasis, the pathophysiology of horizontal canal BPPV remains controversial. We seek to analyze vestibular test results of patients with horizontal canal BPPV with ageotropic nystagmus (AHC) and geotropic nystagmus (GHC) in comparison to patients with posterior canal BPPV (PC) to better understand its pathophysiology.

Methods

In a retrospective chart review of adults with BPPV at a tertiary referral balance center, we reviewed the clinical characteristics and compared videonystagmography, caloric, rotary chair, subjective visual vertical (SVV)/ subjective visual horizontal (SVH), and vestibular evoked myogenic potential (VEMP) results between groups.

Results

We included 11 AHC and seven GHC patients and randomly selected 20 PC patients as the comparison group. All groups had a high rate of migraine and low rates of diabetes and head trauma, but no difference between groups. Ipsilateral caloric weakness was more prevalent in the GHC group compared to the PC group (p=0.02). One of two AHC patients and both GHC patients who had SVV/SVH testing had abnormal findings. The only AHC patient who had ocular VEMP testing had abnormal results. Additionally, we observed a significant downbeating component to nystagmus (4 deg/sec or greater) exclusively in the AHC group (5/10 patients, p=0.001).

Conclusions

Patients with AHC and GHC have unique vestibular testing results. In particular, only AHC patients showed a downbeating component to their nystagmus, which may suggest utricular dysfunction in the pathophysiology of AHC.

Nystagmus Parameters of Supine Roll Test Correlates With Prognosis After Repositioning Maneuver in Horizontal Semicircular Canal Benign Paroxysmal Positional Vertigo

Background: Positional nystagmus induced by supine roll test is characteristic for diagnosing horizontal semicircular canal benign paroxysmal positional vertigo (HC-BPPV). In this study, we aimed to explore the value of nystagmus parameters in by supine roll test (SRT) as prognostic factors in HC-BPPV.

Methods: We retrospectively analyzed the nystagmus parameters of 813 patients diagnosed with HC-BPPV by the SRT model in the SRM-IV system through video nystagmography. Then we used the computer-controlled canalith repositioning procedure (CCRP) mode for treatment. Based on the outcomes, patients were divided into either the cured group or the resistant group. The 1:1 propensity score matching (PSM) was applied to minimize potential selection bias. Then univariable and multivariable analyses were performed to identify the association of nystagmus parameters and the efficacy of CCRP.

Results: Among the 813 patients, 99 (12.2%) were classified in the resistant group. The right side of HC-BPPV patients was twice the number of the left side patients (537 vs. 276). PSM is used to pair resistant patients to the cured patients, in which 99 pairs were successfully matched. Results of univariate and multivariate analyses showed that patients in the resistant group have longer latency in the affected side [odds ratio (OR) = 1.231 (1.110–1.366); P < 0.001] and slower slow phase velocity (SPV) in the healthy side [OR = 0.957 (0.917–0.999); P = 0.045].

Conclusion: Nystagmus parameters may represent the characteristics of canalith. HC-BPPV patients with a longer latency in the affected side and slower SPV on the healthy side during SRT have a higher risk of HC-BPPV persisting after a single CCRP.

Ductus Reuniens and Its Possible Role in Menière's Disease

OBJECTIVE

After 160 years the true underlying cause of Meniere's disease remains enigmatic. The aim of our study is to discuss the possible implication of an obstruction of the ductus reuniens as a cause in Menière's disease.

METHODOLOGY

We first conducted an historical study of the description of the ductus reuniens. We then reviewed the literature regarding ductus reuniens obstruction in animal experiments, human post-mortem studies and living ear imaging. We completed its description by modern microCT imaging. Limited knowledge on the fate of dislodged saccular otoconia is summarized. The possible implications for Meniere's attacks are discussed.

RESULTS

Victor Hensen was the first to describe the ductus reuniens in 1863. He described its length and width and predicted that saccular otoconia might enter the ductus and the cochlea. On microCT the narrowest width of the human ductus reuniens was 0.14 mm. The literature reports cochlear endolymphatic hydrops occurring after animal experimental obstruction of the duct. Human postmortem studies have confirmed saccular otoconial clumps entering the ductus and the cochlea. A postmortem study has shown sites of endolymphatic obstruction, and imaging speculates on blockages in ears with Meniere's disease. Dislodged utricular otoconia can be in clumps of otolithic membranes.

CONCLUSION

Blockages of the ductus reuniens and at other endolymphatic system sites appear to be a feature in Meniere's disease ears. The blockages have been postulated to be saccular otoconia either causing or aggravating hydrops. This could be consistent with observed nystagmus reversals during attacks as the endolymphatic sac attempts to clear the hydrops and the otoconia.

Evaluation of retrootolithic function using galvanic vestibular-evoked myogenic potentials in patients with benign paroxysmal positional vertigo

PURPOSE

The purpose is to investigate possible vestibulopathy in patients with benign paroxysmal positional vertigo (BPPV), inner ear tests, including cervical and ocular vestibular-evoked myogenic potentials (cVEMPs and oVEMPs) via various stimulation modes, were adopted.

METHODS

Fifty BPPV patients were enrolled in this study. All patients underwent pure tone audiometry, cVEMPs, oVEMPs, and caloric tests. The recurrence status, abnormal rates of inner ear tests, and the characteristic parameters of VEMPs, such as wave latencies and amplitudes, were analyzed.

RESULTS

In affected ears, the abnormal rates of acoustic cVEMPs, vibratory oVEMPs, galvanic cVEMPs, and galvanic oVEMPs were 62%, 28%, 36%, and 14%, respectively. The abnormalities of acoustic cVEMPs were significantly larger than those of vibratory oVEMPs, and acoustic/vibratory VEMPs had significantly higher abnormal rates than the corresponding galvanic VEMPs.

CONCLUSION

BPPV patients may have both otolithic and neural dysfunctions. Otolithic organ damage occurs more frequently than retrootolithic neural degeneration, and the saccular macula might have a greater extent of damage than the utricular macula.

Automatic Semicircular Canal Segmentation of CT Volumes Using Improved 3D U-Net with Attention Mechanism

The vestibular system is the sensory apparatus that helps the body maintain its postural equilibrium, and semicircular canal is an important organ of the vestibular system. The semicircular canals are three membranous tubes, each forming approximately two-thirds of a circle with a diameter of approximately 6.5 mm, and segmenting them accurately is of great benefit for auxiliary diagnosis, surgery, and treatment of vestibular disease. However, the semicircular canal has small volume, which accounts for less than 1% of the overall computed tomography image. Doctors have to annotate the image in a slice-by-slice manner, which is time-consuming and labor-intensive. To solve this problem, we propose a novel 3D convolutional neural network based on 3D U-Net to automatically segment the semicircular canal. We added the spatial attention mechanism of 3D spatial squeeze and excitation modules, as well as channel attention mechanism of 3D global attention upsample modules to improve the network performance. Our network achieved an average dice coefficient of 92.5% on the test dataset, which shows competitive performance in semicircular canals segmentation task.

Serum otolin-1 as a biomarker for benign paroxysmal positional vertigo: a case-control study

OBJECTIVES

This study aimed to evaluate serum otolin-1 levels in patients with benign paroxysmal positional vertigo and to compare these levels with healthy individuals.

METHOD

This was a case-control study. After obtaining institutional ethical committee clearance, the serum level of otolin-1 was calculated in adult individuals (18-75 years old) who were divided into group 1 (patients presenting with benign paroxysmal positional vertigo) and group 2 (healthy patients without benign paroxysmal positional vertigo as the control group). Data analysis was carried out to compare the serum levels in the cases and controls. A p-value less than 0.05 was considered significant.

RESULTS

A total of 70 age-matched individuals (cases, n = 40; controls, n = 30) were included in the study. The mean serum level of otolin-1 was 636.8 pg/ml (range, 259-981 pg/ml) in the group of patients with benign paroxysmal positional vertigo and 236.2 pg/ml (range, 189-370 pg/ml) in the control group. The difference was statistically significant (p = 0.0000).

CONCLUSION

The serum levels of otolin-1 in patients with benign paroxysmal positional vertigo are significantly higher compared with individuals without benign paroxysmal positional vertigo.

Molecular mechanism of calcium induced trimerization of C1q-like domain of otolin-1 from human and zebrafish

The C1q superfamily includes proteins involved in innate immunity, insulin sensitivity, biomineralization and more. Among these proteins is otolin-1, which is a collagen-like protein that forms a scaffold for the biomineralization of inner ear stones in vertebrates. The globular C1q-like domain (gC1q), which is the most conserved part of otolin-1, binds Ca²⁺ and stabilizes its collagen-like triple helix. The molecular details of the assembly of gC1q otolin-1 trimers are not known. Here, we substituted putative Ca²⁺-binding acidic residues of gC1q otolin-1 with alanine to analyse how alanine influences the formation of gC1q trimers. We used human and zebrafish gC1q otolin-1 to assess how evolutionary changes affected the function of the protein. Surprisingly, the mutated forms of gC1q otolin-1 trimerized even in the absence of Ca²⁺, although they were less stable than native proteins saturated with Ca²⁺. We also found that the zebrafish gC1q domain was less stable than the human homologue under all tested conditions and became stabilized at higher concentrations of Ca²⁺, which showed that specific interactions leading to the neutralization of the negative charge at the axis of a gC1q trimer by Ca²⁺ are required for the trimers to form. Moreover, human gC1q otolin-1 seems to be optimized to function at lower concentrations of Ca²⁺, which is consistent with reported Ca²⁺ concentrations in the endolymphs of fish and mammals. Our results allow us to explain the molecular mechanism of assembly of proteins from the C1q superfamily, the modulating role of Ca²⁺ and expand the knowledge of biomineralization of vertebrate inner ear stones: otoliths and otoconia.

Visualization of horizontal canal benign paroxysmal positional vertigo using 3DCT imaging and its assessment

BACKGROUND

There have been no useful imaging methods to diagnose benign paroxysmal positional vertigo (BPPV), a common cause of vertigo, depending on the characteristic symptom.

OBJECTIVE

To visualize horizontal canal (HC) BPPV using 3DCT and assess its clinical usefulness.

SUBJECTS AND METHODS

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).

RESULTS

The HCs of BPPV patients were clearly visualized and the luminal aspects showed differences among ears with cupulolithiasis, canalolithiasis and no symptoms healthy subjects.

CONCLUSIONS AND SIGNIFICANCE

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.

Prevalence of "Reversal Nystagmus" in Benign Paroxysmal Positional Vertigo

PURPOSE

 To investigate the prevalence of reversal nystagmus in individuals with benign paroxysmal positional vertigo (BPPV).

STUDY DESIGN

 Prevalence of reversal nystagmus was assessed in 28 subjects with unilateral posterior canal BPPV, canalithiasis type. Six trials of Dix-Hallpike testing were completed for each subject.

RESULTS

 Reversal nystagmus was present in 129 out of 167 Dix-Hallpike maneuvers that were performed (77.2%). In 19 trials where nystagmus was absent with the dependent position of Dix-Hallpike testing, reversal nystagmus was nonetheless demonstrated in 11 trials (57.9%).

CONCLUSION

 Reversal nystagmus is commonly demonstrated in individuals with posterior canal BPPV, canalithiasis type. It is frequently evoked even when there is no nystagmus with the dependent position of Dix-Hallpike testing. Observation of reversal nystagmus may enhance the identification of BPPV during Dix-Hallpike testing.

[Various types of vertigo and balance disorders in patients with Meniere's disease]

Vertigo and balance disorders in Meniere's disease (MD) may have various etiology. The aim of the review is discussing pathogenetic mechanisms of the typical vertiginous paroxysms in MD, resulting from endolymphatic hydrops as well as analysis of etiology, pathogenesis, clinical course and basic treatment of paroxysmal and permanent forms of vertigo and balance disorders, caused by other conditions, associated with MD. We discussed the course of MD complicated by vestibular migraine, benign positional paroxysmal vertigo, functional dizziness, bilateral vestibulopathy and vestibular drop-attacks.

An evaluation of serum Otolin-1 & Vitamin-D in benign paroxysmal positional vertigo

BACKGROUND

Serum otolin-1 is an inner ear protein exclusively expressed in otoconia and cells of vestibule and cochlea. Serum otolin-1 is found to be quantifiable in patients with BPPV. Low Vitamin-D is associated with pathogenesis of BPPV. Since otoconia degeneration contributes to BPPV, lack of Vitamin-D may impact otoconia structure and integrity.

OBJECTIVE

We aimed at studying the s.otolin-1 as biomarker and significance of vit-D in BPPV.

MATERIAL AND METHOD

23 patients in test and control groups respectively were chosen within the age of 20 to 65 years. All the patients were diagnosed using Dix Hallpike menouver and head roll test, patients were treated with appropriate Canal Reposition Menouver (CRM).

RESULTS

Serum Otolin-1 levels among the test ranged from 366 to 882 pg/mL with mean of 585.17 pg/mL whereas in control group ranged from 223 to 462 pg/mL with mean of 335.26 pg/mL. Mean Vitamin-D levels among the test group was 22.67 ng/mL (Range = 6.3-68.4) and that of control 15.43 pg/mL (Range = 5.4-27.7) respectively. The relationship between the serum Otolin-1 and Vitamin-D was not statistically significant.

CONCLUSION

Otolin-1 levels is increased in BPPV patients and is sensitive in BPPV, specificity needs to be validated. Role of vitamin-D with respect to inner ear proteins needs further investigation.

Comparison of associated comorbid conditions in patients with benign paroxysmal positional vertigo with or without migraine history: A large single institution study

PURPOSE

In the largest reported United States (U.S.) cohort of benign paroxysmal positional vertigo (BPPV), does the presence or absence of migraine correlate with increased associations of other factors?

MATERIALS & METHODS

A retrospective chart review from a single U.S. neurotology center. Adult patients with BPPV from 2003 to 2017 classified into two groups: 1) with migraine; 2) without migraine.

RESULTS

The prevalence of self-reported migraine history in a BPPV-positive population (n = 1481) was 25.8% (n = 382). Among those with BPPV and migraine, 88.5% were female, 8.1% had diabetes, 22.5% had prior history of BPPV, 8.9% had Meniere's disease and recurrence rate was 38.3%. No statistically significant differences between recurrence or resolution rates between the two groups were demonstrated (p > 0.05). Adjusted logistic regression model found that women and those with a prior history of BPPV had significantly higher odds of having both BPPV and migraine conditions compared to their counterparts. In contrast, older age and diabetes were associated with significantly lower odds of concomitant BPPV and migraine.

CONCLUSIONS

The prevalence of migraine among the study sample was 25.8%. Female gender, prior history of BPPV, younger age, and lack of diabetes were independently associated with the concurrent comorbidity of BPPV and migraine. These data further substantiate previously reported rates (from smaller studies); and, demonstrate that recurrence and resolution rates are not worse in those with BPPV and migraine compared to the general BPPV population. Findings support an association between migraine and BPPV and enhances one's ability to accurately counsel patients regarding these diseases.

Feasibility of Using the Video-Head Impulse Test to Detect the Involved Canal in Benign Paroxysmal Positional Vertigo Presenting With Positional Downbeat Nystagmus

Positional downbeat nystagmus (pDBN) represents a relatively frequent finding. Its possible peripheral origin has been widely ascertained. Nevertheless, distinguishing features of peripheral positional nystagmus, including latency, paroxysm and torsional components, may be missing, resulting in challenging differential diagnosis with central pDBN. Moreover, in case of benign paroxysmal positional vertigo (BPPV), detection of the affected canal may be challenging as involvement of the non-ampullary arm of posterior semicircular canal (PSC) results in the same oculomotor responses generated by contralateral anterior canal (ASC)-canalolithiasis. Recent acquisitions suggest that patients with persistent pDBN due to vertical canal-BPPV may exhibit impaired vestibulo-ocular reflex (VOR) for the involved canal on video-head impulse test (vHIT). Since canal hypofunction normalizes following proper canalith repositioning procedures (CRP), an incomplete canalith jam acting as a "low-pass filter" for the affected ampullary receptor has been hypothesized. This study aims to determine the sensitivity of vHIT in detecting canal involvement in patients presenting with pDBN due to vertical canal-BPPV. We retrospectively reviewed the clinical records of 59 consecutive subjects presenting with peripheral pDBN. All patients were tested with video-Frenzel examination and vHIT at presentation and after resolution of symptoms or transformation in typical BPPV-variant. BPPV involving non-ampullary tract of PSC was diagnosed in 78%, ASC-BPPV in 11.9% whereas in 6 cases the involved canal remained unidentified. Presenting VOR-gain values for the affected canal were greatly impaired in cases with persistent pDBN compared to subjects with paroxysmal/transitory nystagmus (p < 0.001). Each patient received CRP for BPPV involving the hypoactive canal or, in case of normal VOR-gain, the assumed affected canal. Each subject exhibiting VOR-gain reduction for the involved canal developed normalization of vHIT data after proper repositioning (p < 0.001), proving a close relationship with otoliths altering high-frequency cupular responses. According to our results, overall vHIT sensitivity in detecting the affected SC was 72.9%, increasing up to 88.6% when considering only cases with persistent pDBN where an incomplete canal plug is more likely to occur. vHIT should be routinely used in patients with pDBN as it may enable to localize otoconia within the labyrinth, providing further insights to the pathophysiology of peripheral pDBN.

Correlation Between Benign Paroxysmal Positional Vertigo and 25-hydroxyvitamin D

Objective: The correlation between benign paroxysmal positional vertigo (BPPV) and vitamin D levels was controversial. We explored age- and sex-related effects on 25-hydroxyvitamin D (25(OH)D) and correlation between 25(OH)D levels and BPPV.

Subjects and Methods: We recruited 380 patients with BPPV and collected 25(OH)D records of 3,125 control subjects who were further divided into age- and sex-based subgroups. We respectively investigated the effects of sex and age on 25(OH)D by comparing sex- or age-based subgroups. Then, we separately compared levels of 25(OH)D in sex-and age-based subgroups between the BPPV and control group.

Results: 25(OH)D levels in male subgroups were significant higher than those in female subgroup both in the BPPV and control group. With increasing age, 25(OH)D levels gradually increased, and there were significant between-subgroup differences for age in the control group. In males, the significant between-subgroup difference was observed only in the <40 year subgroup. Three female age-matched subgroups (<40, 40–49, and 60–69) showed significant between-subgroup differences.

Conclusions: There are sex and age differences in vitamin D levels. For both male and female patients with BPPV aged <40 years and female patients with BPPV aged 40–49 and 60–69 years, the lower vitamin D level is a risk factor for BPPV. In female patients with BPPV aged 50–59 and >70 years, and male patients with BPPV aged >40 years, the correlation between vitamin D and BPPV is non-existent.

[Current aspects of vertigo and dizziness in advanced age]

Vertigo and dizziness in advanced age are common complaints in daily clinical practice. The otorhinolaryngologist holds a central position in the differential diagnostic clarification. Age-related disorders (e.g. benign positional vertigo, presbyvestibulopathy, otholith functional disorders) arise due to a physiological, individually distinct and objectively detectable reduction in the sensitivity of sensory and extrasensory elements of the vestibular system. They may reach pathological significance if these dysfunctions affect the physical and emotional well-being (e.g. gait disturbances and falls with subsequent morbidity). Disorders accompanying aging (e.g. neurological, cardiovascular or psychiatric) can occur simultaneously with age-related changes in sensory function. The identification, especially with respect to the risk of falling in older people and the development of individual therapeutic strategies is an interdisciplinary task. Besides a causative therapy, strength, coordination and balance training contribute to the treatment of equilibrium disorders and falls from the perspective of evidence-based medicine.

Cardiovascular Risk Factors and Benign Paroxysmal Positional Vertigo in Community Otolaryngology-Head and Neck Surgery

OBJECTIVE

Cardiovascular risk factors have been associated with benign paroxysmal positional vertigo (BPPV), possibly causing degeneration of the utricular epithelium and subepithelium, but supportive evidence is mixed. This is the first study to examine the association between cardiovascular risk factors and BPPV as they present in the community practice of comprehensive otolaryngology-head and neck surgery.

STUDY DESIGN

Cross-sectional case-matched case-control series.

SETTING

A community practice of otolaryngology-head and neck surgery with 3 clinical offices and a socioeconomically diverse patient population.

SUBJECTS AND METHODS

Clinical data were collected retrospectively from the electronic health records of a continuous 4-year series of 628 patients with BPPV and age- and sex-matched controls.

RESULTS

There were no statistically significant associations found between BPPV and diabetes, hypertension, dyslipidemia, or body mass index in the study population in pairwise comparisons or multivariable modeling.

CONCLUSION

This study suggests that BPPV as encountered in a community ear, nose, and throat practice is not generally associated with cardiovascular risk factors. The possibility that these or other cardiovascular risk factors may be causative in some cases cannot be excluded, though most cases of BPPV appear to be caused primarily by shedding of otoconia from the utricle that is idiopathic or at least in part by unconfirmed noncardiovascular factors.

Horizontal semicircular canal jam: Two new cases and possible mechanisms

INTRODUCTION

Benign paroxysmal positional vertigo (BPPV) of the horizontal semicircular canal (hSCC) can present with otoconia blocking its lumen (canalith jam), with signs and symptoms that make it difficult to distinguish from central nervous system pathology.

OBJECTIVE

Here we report two cases of canalith jam affecting the hSCC and offer a theoretical mechanism based on known vestibular neurophysiology.

METHODS

We use video-oculography to document the canalith jam and show the moment the otoconia loosen.

RESULTS

Canalith jam is a rare form of BPPV remedied with repositioning maneuvers.

CONCLUSION

Clinicians should consider canalith jam as a mechanism for BPPV when the nystagmus is (a) Direction fixed with fixation removed and during positional testing; (b) Velocity dependent on supine head position; (c) Converts to geotropic directional changing nystagmus.

A mouse model for benign paroxysmal positional vertigo with genetic predisposition for displaced otoconia

Abnormal formation of otoconia, the biominerals of the inner ear, results in balance disorders. The inertial mass of otoconia activates the underlying mechanosensory hair cells in response to change in head position primarily during linear and rotational acceleration. Otoconia associate exclusively with the two gravity receptors, the utricle and saccule. The cristae sensory epithelium is associated with an extracellular gelatinous matrix known as cupula, equivalent to otoconia. During head rotation, the inertia of endolymphatic fluids within the semicircular canals deflects the cupula of the corresponding crista and activates the underlying mechanosensory hair cells. It is believed that detached free-floating otoconia particles travel ectopically to the semicircular canal and cristae and are the culprit for benign paroxysmal positional vertigo (BPPV). The Slc26a4 mouse mutant harbors a missense mutation in pendrin. This mutation leads to impaired transport activity of pendrin and to defects in otoconia composition and distribution. All Slc26a4 ^loop/loop homozygous mutant mice are profoundly deaf but show inconsistent vestibular deficiency. A panel of behavioral tests was utilized in order to generate a scoring method for vestibular function. A pathological finding of displaced otoconia was identified consistently in the inner ears of mutant mice with severe vestibular dysfunction. In this work, we present a mouse model with a genetic predisposition for ectopic otoconia with a clinical correlation to BPPV. This unique mouse model can serve as a platform for further investigation of BPPV pathophysiology, and for developing novel treatment approaches in a live animal model.

Benign Positional Paroxysmal Vertigo Treatment: a Practical Update

PURPOSE OF THE REVIEW

To define the best up-to-date practical approach to treat benign paroxysmal positional vertigo (BPPV).

RECENT FINDINGS

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.

Reflections on the Last 25 Years of the American Otological Society and Thoughts on its Future

PURPOSE

To review contributions of the American Otological Society (AOS) over the most recent quarter century (1993-2018) and to comment on possible future evolution of the field during the quarter century to come.

METHODS

Retrospective review of selected topics from the AOS transactions, distinguished lectureships over the past 25 years, and selective reflection by the authors. Speculation on potential advances of the next quarter century derived from emerging topics in the current literature and foreseeable trends in science and technology are also proffered for consideration (and possible future ridicule).

RESULTS

Integration of multiple disciplines including bioengineering, medical imaging, genetics, molecular biology, physics, and evidence based medicine have substantially benefitted the practice of otology over the past quarter century. The impact of the contributions of members of the AOS in these developments cannot be over estimated.

CONCLUSIONS

Further scientific advancement will certainly accelerate change in the practice of otologic surgery and medicine over the coming decade in ways that will be marvelous to behold.

Dizziness handicap and clinical characteristics of posterior and lateral canal BPPV

PURPOSE

Benign paroxysmal positional vertigo (BPPV) is diagnosed and divided into subtypes based on positioning vertigo and nystagmus. Whether these subtypes entail any significant differences in patient-reported symptoms; is yet not known. Such differences may have clinical and therapeutic consequences. Our aim was to assess dizziness handicap and clinical characteristics of posterior and lateral canal BPPV.

METHODS

This prospective observational multicentre study analysed consecutive patients with BPPV, confirmed by standardized procedures including videonystagmography under diagnostic manoeuvres in a biaxial rotational chair. Patients were screened for other neurological and otological disorders.

OUTCOMES

Dizziness handicap inventory (DHI), posterior vs. lateral canal involvement.

FACTORS

age, gender, positional nystagmus intensity (maximum slow-phase velocity), symptom duration, 25-hydroxyvitamin D-level and traumatic aetiology.

RESULTS

132 patients aged 27-90 (mean 57, SD 13) years were included. Higher DHI scores were associated with lateral canal BPPV [95% CI (1.59-13.95), p = 0.01] and female gender [95% CI (0.74-15.52), p = 0.03]. Lateral canal BPPV was associated with longer symptom duration [OR 1.10, CI (1.03-1.17), p = 0.01] and lower 25-hydroxyvitamin D-levels [OR 0.80, CI (0.67-0.95), p = 0.03]. There was no correlation between DHI scores and nystagmus intensity.

CONCLUSIONS

This study suggests that patients with lateral canal BPPV have increased patient-perceived disability, lower vitamin D-levels and longer duration of symptoms. This subtype might therefore require closer follow-up. Patient-perceived disability is not related to positional nystagmus intensity.

A Chair-based Abbreviated Repositioning Maneuver (ChARM) for fast treatment of posterior BPPV

PURPOSE

To assess the effectiveness of a variation of the Epley maneuver, which we have titled "Chair-based Abbreviated Repositioning maneuver (ChARM)", in solving cases of benign positional paroxysmal vertigo (BPPV) of the posterior canal. ChARM addresses multiple issues of highly overloaded medical centers that delay its due and timely resolution. For example it does not necessitate an examination bed/table and requires only a backed chair, and less than 3 min to be performed. In combination with a recently published abbreviated diagnostic maneuver it can solve BPPV cases within few minutes of single medical visit.

METHODS

Patients being diagnosed with posterior BPPV by means of an abbreviated diagnostic maneuver were recruited. Immediately after diagnosis, a single attempt of ChARM was conducted. The patient was followed for 48 h and at 1 month after these procedures to assess the persistence of symptomatology.

RESULTS

124 patients were treated with ChARM immediately after diagnosis during their very first medical visit. 92 patients (74.2%) solved their symptomatology completely after a single attempt of ChARM. The absence of symptoms persisted during the 30 days of follow-up.

DISCUSSION

ChARM showed high success rates in solving posterior BPPV. The entire diagnostic-treatment procedure takes less than 5 min to perform and may allow direct treatment of patients, thereby avoiding unnecessary referrals or full vestibular testing. These abbreviated tools may be particularly useful in primary care settings or heavily overloaded otolaryngology or neurology departments.

Difference in Serum Levels of Vitamin D Between Canalolithiasis and Cupulolithiasis of the Horizontal Semicircular Canal in Benign Paroxysmal Positional Vertigo

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.

Benign paroxysmal positional vertigo

Objectives

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular end‐organ disease. This article aims to summarize research findings and key discoveries of BPPV. The pathophysiology, diagnosis, nonsurgical, and surgical management are discussed.

Methods

A comprehensive review of the literature regarding BPPV up through June 2018 was performed.

Results

BPPV is typified by sudden, brief episodes of vertigo precipitated by specific head movements. While often self‐limited, BPPV can have a considerable impact on quality of life. The diagnosis can be established with a Dix‐Hallpike maneuver for the posterior and anterior canals, or supine roll test for the horizontal canal, and typically does not require additional ancillary testing. Understanding the pathophysiology of both canalithiasis and cupulolithiasis has allowed for the development of various repositioning techniques. Of these, the particle repositioning maneuver is an effective way to treat posterior canal BPPV, the most common variant. Options for operative intervention are available for intractable cases or patients with severe and frequent recurrences.

Conclusions

A diagnosis of BPPV can be made through clinical history along with diagnostic maneuvers. BPPV is generally amenable to in‐office repositioning techniques. For a small subset of patients with intractable BPPV, canal occlusion can be considered.

Level of Evidence

N/A

Causes of Persistent Positional Vertigo Following Posterior Semicircular Canal Occlusion for Benign Paroxysmal Positional Vertigo

OBJECTIVE

To report causes of persistent recalcitrant positional vertigo (PRPV) after posterior semicircular canal occlusion (PSCO) for benign paroxysmal positional vertigo (BPPV).

STUDY DESIGN

Retrospective chart review.

SETTING

Single high-volume otology practice.

PATIENTS

Patients diagnosed with BPPV from 2007 to 2017.

INTERVENTION

PSCO and follow-up care including diagnostic and particle repositioning maneuvers for recurrent BPPV.

MAIN OUTCOME MEASURES

PRPV, defined as recalcitrant positional vertigo for any reason following PSCO.

RESULTS

Twenty seven PSCO operations were performed in 26 patients. Twenty five patients (96.2%) had resolution of the Dix-Hallpike test in the operated ear. Eleven patients (42.3%) developed BPPV postoperatively, three (11.5%) in the operated ear and eight (30.8%) in the contralateral ear. Five of eight patients (62.5%) who developed contralateral BPPV had unilateral BPPV preoperatively. Eight patients (30.8%) developed BPPV at least twice after surgery or did not resolve, qualifying as PRPV, and all but one of these events occurred in the nonsurgical ear. No instances of cerebrospinal fluid leak, postoperative infection, facial palsy, clinically significant hearing loss, or death occurred.

CONCLUSIONS

PSCO is a safe and effective option for recalcitrant BPPV. However, 30.8% of patients, including patients with initially unilateral BPPV, had recalcitrant positional vertigo postoperatively, usually due to contralateral BPPV. Patients considering PSCO should be counseled regarding this risk to ensure realistic expectations.

Saccular otoconia as a cause of Ménière's disease: hypothesis based on two theories

BACKGROUND

The cause of Ménière's disease remains enigmatic after 156 years. Schuknecht's rupture and potassium intoxication theory of attacks was based on histological studies.

OBJECTIVES

This paper aimed to: present the most contemporary evidence indicating that ruptures do not usually occur, and discuss the possibility that detached saccular otoconia are the main cause of Ménière's disease; and to establish an unequivocal definition of the age of Ménière's disease onset.

METHOD

The paper reviews the electrophysiological basis of the Gibson-Arenberg drainage theory used to explain vertigo attacks. The current, limited knowledge of the likely fate of detached saccular otoconia is discussed.

RESULTS

Electrophysiological studies during attacks do not support endolymph ruptures, but rather endolymph flowing in one direction and then in the opposite direction. Age of onset for Ménière's disease parallels that for benign paroxysmal positional vertigo.

CONCLUSION

The similarity of age of onset spectrum for Ménière's disease and benign paroxysmal positional vertigo raises the possibility that the two conditions have the same fundamental cause.

Tumarkin-like phenomenon as a sign of therapeutic success in benign paroxysmal positional vertigo

ABSTRACT Objective: To describe an unusual patient reaction to maneuvers used in the treatment of posterior canal benign paroxysmal positional vertigo (PC-BPPV) that we termed the “Tumarkin-like phenomenon”. Methods: At a private practice, 221 outpatients were diagnosed and treated for PC-BPPV. The treatment consisted of performing the Epley or Semont maneuvers. At the end of these maneuvers, when assuming the sitting position, the patients’ reactions were recorded. Results: Thirty-three patients showed a Tumarkin-like phenomenon described by a self-reported sensation of suddenly being thrown to the ground. In the follow-up, this group of patients remained without PC-BPPV symptoms up to at least 72 hours after the maneuvers. Conclusion: The occurrence of a Tumarkin-like phenomenon at the end of Epley and Semont maneuvers for PC-BPPV may be linked with treatment success.

Treatment of Patients With Benign Paroxysmal Positional Vertigo and Severe Immobility Using the Particle Repositioning Chair: A Retrospective Cohort Study

OBJECTIVE

To report treatment of benign paroxysmal positional vertigo (BPPV) in patients unable to undergo traditional canalith repositioning maneuvers (CRMs) using a particle repositioning chair (PRC).

METHODS

A retrospective chart review was conducted at a single high-volume otology practice of patients diagnosed with BPPV from 2007 to 2017 with immobility prohibiting use of traditional CRMs. Patients were diagnosed and treated using a PRC, and outcome measures including resolution, recurrence, and number of treatment visits were recorded.

RESULTS

A total of 34 patients meeting criteria were identified, 24 of whom had cervical spine disease and 10 of whom had other prohibitive immobility. Symptoms were present for between 5 days and 11 years at presentation, with mean and median of 552 and 90 days, respectively. Symptoms resolved in 68% of patients and recurred in 13% of those patients. Most patients required 1 treatment visit.

CONCLUSIONS

Successful treatment of patients with BPPV and concomitant immobility prohibiting traditional CRMs is reported using the PRC. Benign paroxysmal positional vertigo in the setting of immobility is an indication for treatment with a PRC if available.

Analysis of non-posterior canal benign paroxysmal positional vertigo in patients treated using the particle repositioning chair: A large, single-institution series

PURPOSE

Benign paroxysmal positional vertigo (BPPV) involving the horizontal and superior semicircular canals is difficult to study due to variability in diagnosis. We aim to compare disease, treatment, and outcome characteristics between patients with BPPV of non-posterior semicircular canals (NP-BPPV) and BPPV involving the posterior canal only (P-BPPV) using the particle repositioning chair as a diagnostic and therapeutic tool.

METHODS

Retrospective review of patients diagnosed with and treated for BPPV at a high volume otology institution using the particle repositioning chair.

RESULTS

A total of 610 patients with BPPV were identified, 19.0% of whom had NP-BPPV. Patients with NP-BPPV were more likely to have bilateral BPPV (52.6% vs. 27.6%, p < 0.0005) and Meniere's disease (12.1% vs. 5.9%, p = 0.02) and were more likely to have caloric weakness (40.3% vs. 24.3%, p = 0.01). Patients with NP-BPPV required more treatments for BPPV (average 3.4 vs. 2.4, p = 0.01) but did not have a significantly different rate of resolution, rate of recurrence, or time to resolution or recurrence than patients with posterior canal BPPV.

CONCLUSIONS

Comparison of NP-BPPV and P-BPPV is presented with reliable diagnosis by the particle repositioning chair. NP-BPPV affects 19% of patients with BPPV, and these patients are more likely to have bilateral BPPV and to require more treatment visits but have similar outcomes to those with P-BPPV. NP-BPPV is common and should be part of the differential diagnosis for patients presenting with positional vertigo.

Vitamin D supplementation may improve symptoms in Meniere's disease

In the last 4 years the authors observed a trend that correcting vitamin D deficiency in newly diagnosed cases of Meniere's disease decreased the necessity of the ablative therapy with intratympanic gentamicin. According to their hypothesis, vitamin D supplementation may indeed have a beneficial effect in Meniere's disease if the symptoms are caused by a local postviral autoimmune reaction. Vitamin D has a strong immunomodulatory role, one of which is the regulation of the expression of pro-inflammatory mediators. The authors suggest further epidemiological studies to decide if there is a connection between vitamin D deficiency and Meniere's disease.