Benign paroxysmal positional vertigo and its variants

Comparative Study of Clinical Features of Patients with Different Types of Benign Paroxysmal Positional Vertigo

Objectives: Even though BPPV is one of the most common causes of vertigo, it is often underdiagnosed and omitted in the diagnosis of patients reporting vertigo. The aim of the study was to establish a diagnostic pattern useful in patients admitted due to vertigo, based on the most common clinical characteristics of patients suffered from posterior canal BPPV (PC-BPPV), horizontal canal BPPV with geotropic (HCG-BPPV) and apogeotropic nystagmus (HCA-BPPV). Methods: The analysis covered the results obtained in 105 patients with a positive result of the Dix-Hallpike maneuver or the supine roll test. The patients were divided into 3 groups based on the BPPV type: gr.1:PC-BPPV (60%); gr.2: HCG-BPPV (27%); gr.3: HCA-BPPV (13%). Patients before the diagnostic maneuvers filled the questionnaire concerning their symptoms and previous diseases. Results: Almost all patients had vertigo during turning over in bed and the character of the symptoms was paroxysmal. The answers to questions about the type of head movement evoked vertigo and how long vertigo lasted were differentiating. The percentages of correct diagnosis speculated by the combined answers were 69.6% in PC-BPPV, 61.8% in HCG-BPPV, and 80% in HCA-BPPV. Conclusions: Basing on those observations there is presented the diagnostic schedule which could be useful in dizziness examination. The above results indicate that a properly collected interview with the patient allows for a high percentage of accurate diagnosis.

Gait and Falls in Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-analysis

BACKGROUND AND PURPOSE

Benign paroxysmal positional vertigo (BPPV) is one of the most common vestibular disorders, and is treated effectively with particle repositioning maneuvers (PRM). The aim of this study was to assess the influence of BPPV and treatment effects of PRM on gait, falls, and fear of falling.

METHODS

Three databases and the reference lists of included articles were systematically searched for studies comparing gait and/or falls between (1) people with BPPV (pwBPPV) and controls and (2) pre- and posttreatment with PRM. The Joanna Briggs Institute critical appraisal tools were used to assess risk of bias.

RESULTS

Twenty of the 25 included studies were suitable for meta-analysis. Quality assessment resulted in 2 studies with high risk of bias, 13 with moderate risk, and 10 with low risk. PwBPPV walked slower and demonstrated more sway during tandem walking compared with controls. PwBPPV also walked slower during head rotations. After PRM, gait velocity during level walking increased significantly, and gait became safer according to gait assessment scales. Impairments during tandem walking and walking with head rotations did not improve. The number of fallers was significantly higher for pwBPPV than for controls. After treatment, the number of falls, number of pwBPPV who fell, and fear of falling decreased.

DISCUSSION AND CONCLUSIONS

BPPV increases the odds of falls and negatively impacts spatiotemporal parameters of gait. PRM improves falls, fear of falling, and gait during level walking. Additional rehabilitation might be necessary to improve gait while walking with head movements or tandem walking.Video Abstract available for more insights from the authors (see the Supplemental Digital Content Video, available at: http://links.lww.com/JNPT/A421 ).

Efficacy of Epley's maneuver plus betahistine in the management of PC-BPPV: A systematic review and meta-analysis

BACKGROUND

To evaluate the efficacy of Epley's maneuver plus betahistine in the management of patients with posterior canal benign paroxysmal positional vertigo (PC-BPPV).

METHODS

Electronic databases including PubMed, Embase, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, and Wanfang were searched from their inception to April, 2022. The effect size was analyzed by calculating the pooled risk ratio estimates of efficacy rate, recurrence rate, and standardized mean differences (SMD) of dizziness handicap inventory (DHI) score with a 95% confidence interval (CI). Sensitive analysis was performed simultaneously.

RESULTS

A total of 9 randomized controlled trials with 860 PC-BPPV patients were included in the meta-analysis, in which 432 were treated with Epley's maneuver plus betahistine, and 428 received Epley's maneuver alone. The meta-analysis revealed that Epley's maneuver plus betahistine significantly improved DHI score than Epley's maneuver alone (SMD = -0.61, 95% CI -0.96 to -0.26, P = .001). In addition, both Epley's maneuver plus betahistine and Epley's maneuver groups had comparable outcomes in efficacy rate and recurrence rate.

CONCLUSION

This meta-analysis shows that Epley's maneuver plus betahistine in PC-BPPV patients had favorable effects on DHI score.

The Impact of the Angular Head Movement's Velocity during Diagnostic Maneuvers on Proper Benign Positional Paroxysmal Vertigo Diagnosis and Therapy

Based on the current state of the BPPV field, there are no guidelines that specify an angular head movement's velocity (AHMV) during diagnostic maneuvers of BPPV. The aim of this study was to evaluate the impact of AHMV during diagnostic maneuvers on proper BPPV diagnosis and therapy. The analysis covered the results obtained in 91 patients with a positive result of the Dix-Hallpike (D-H) maneuver or the roll test. The patients were divided into four groups based on values of AHMV (high 100-200°/s and low 40-70°/s) and the BPPV type (posterior: PC-BPPV or horizontal: HC-BPPV). The parameters of the obtained nystagmuses were analyzed and compared to AHMV. There was a significant negative correlation between AHMV and latency of nystagmus in all study groups. Furthermore, there was a significant positive correlation between AHMV and both maximum slow phase velocity and average frequency of nystagmus in the PC-BPPV groups, whereas it was not observed in the HC-BPPV patients. Complete relief of symptoms was reported after 2 weeks and was better in patients diagnosed with maneuvers performed with high AHMV. High AHMV during the D-H maneuver allows the nystagmus to be more visible, increasing the sensitivity of diagnostic tests and is crucial for a proper diagnosis and therapy.

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.

Less talked variants of benign paroxysmal positional vertigo

The diagnostic criteria were established for benign paroxysmal positional vertigo (BPPV), the most common vestibular disorder worldwide, by the Barany Society in 2015. This marked an important milestone in the diagnosis and treatment of BPPV. However, there still remain uncertainties and ambiguities regarding the clinical features and pathophysiology of BPPV, and its clinical variants. In this manuscript, we will discuss 1) the emerging and controversial syndromes of BPPV (i.e., canalolithiasis of the anterior canal, cupulolthiasis of the posterior canal, and lithiasis of multiple canals) with updates, 2) atypical nystagmus according to the canal involved (e.g., nystagmus induced by head position changes in the pitch plane in horizontal canal BPPV, and positional downbeat nystagmus in posterior canal BPPV), 3) persistent geotropic positional nystagmus. Consideration of these uncommon types and manifestations of BPPV would broaden our understanding of BPPV pathomechanisms and allow differentiation from central vertigo and nystagmus.

Immediate Improvement in Subjective Visual Vertical and Disequilibrium Predicts Resolution of Benign Paroxysmal Positional Vertigo Following Single Canalith Repositioning Maneuver

Objective

To evaluate whether immediate post-canalith repositioning maneuver (CRM) vestibular changes are predictive of benign paroxysmal positional vertigo (BPPV) resolution.

Study Design

Retrospective cohort study.

Setting

Tertiary referral center.

Patients

Adults (n = 27) with posterior canal BPPV.

Interventions

Single CRM with Frenzel goggles.

Main Outcome Measures

The Visual Analog Scale (VAS) for disequilibrium, the subjective visual vertical (SVV), the subjective visual horizontal (SVH), and the Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) were administered pre- and immediately following single CRM. Dix-Hallpike was performed 1-3 weeks after CRM to assess for BPPV resolution. Pre- and post-treatment vestibular assessments were compared between groups to determine if post-CRM vestibular changes could predict BPPV resolution.

Results

The change in VAS score following CRM treatment was statistically different between patients who responded to CRM treatment (n = 15) and those who did not (n = 12), (-0.07 points versus -2.40 points, respectively; P = 0.03). Likewise, a significantly greater improvement in SVV score was observed for CRM responders compared with CRM nonresponders (0.92° versus -0.06°, respectively; P = 0.02). Change in SVH and mCTSIB scores did not differ significantly between groups. Additionally, patient age was found to predict outcome of CRM treatment, with older patients more likely to experience persistent BPPV (P ≤ 0.01).

Conclusions

Immediate improvement in VAS and SVV scores following CRM may be useful in predicting resolution of BPPV and may assist in directing the timing and need for future interventions. Younger age may have a favorable predictive value for improvement following single CRM.

Clinical Application of Different Vertical Position Tests for Posterior Canal-Benign Paroxysmal Positional Vertigo-Cupulolithiasis

Background

Posterior canal-benign paroxysmal positional vertigo-cupulolithiasis (PC-BPPV-cu) is a new and controversial type of benign paroxysmal positional vertigo (BPPV). At present, there are few relevant clinical studies as to whether the Half Dix-Hallpike test (Half D-HT) induces more obvious nystagmus than the Dix Hallpike test (D-HT) and straight head hanging test (SHH) in patients with PC-BPPV-cu.

Objectives

To investigate the clinical characteristics of PC-BPPV-cu, and analyze the diagnostic significance of the Dix-Hallpike test (D-HT), Half D-HT, and straight head hanging (SHH) test in these patients.

Methods

A total of 46 patients with PC-BPPV-cu were enrolled, and divided into two groups (N = 23): a group A (induction order: D-HT, Half D-HT, SHH) and a group B (induction order: Half D-HT, D-HT, SHH).

Results

Among 46 patients with PC-BPPV-cu, the bilateral and unilateral abnormality rates of the disease side were 5 cases and 41 cases, respectively. There were significant differences in the proportion of torsional-upbeating nystagmus and upbeating nystagmus among the three headhanging positions in 46 patients with PC-BPPV-cu (P < 0.001). The slow phase velocity (SPV) of induced nystagmus at half D-HT supine position was slower than D-HT supine position (P < 0.05) and SHH supine position (P < 0.05). The nystagmus latency of D-HT supine position was significantly shorter than half D-HT (P < 0.05) and SHH (P < 0.05). PC-BPPV-cu patients were accompanied by 53.5% semicircular canal paresis, 69.6% audiological abnormalities, 76% cervical vestibular evoked myogenic potential (cVEMP), and 75% video head impulse test (vHIT) abnormalities, the concordance rates of the four detection methods were similar (χ2 = 0.243, P = 0.970).

Conclusions

The Half D-HT is simple and feasible, but might have a risk of false-negative diagnoses of the torsional-upbeating nystagmus and upbeating nystagmus. The D-HT is still a classic induction method for PC-BPPV-cu. The two complement each other and may aid in the diagnosis of PC-BPPV-cu patients. Future clinical applications of Half D-HT require extensive research to determine its diagnostic efficacy.

Prevalence of and Theoretical Explanation for Type 2 Benign Paroxysmal Positional Vertigo

BACKGROUND AND PURPOSE

A variant of benign paroxysmal positional vertigo (BPPV) involves the subjective report of vertigo without the coinciding nystagmus. This presentation includes truncal retropulsion when sitting up from the ipsilesional provocative test (ie, Dix-Hallpike), which we term type 2 BPPV. The primary objective of this study is to prospectively determine the prevalence and describe the clinical course of type 2 BPPV. We offer a theoretical explanation for the absence of nystagmus.

METHODS

Prospective, observational study carried out in 2 tertiary hospitals. One hundred eighty patients (134 women, 46 men) met the inclusion criteria and were included between January 10, 2018, and October 30, 2019. Efficacy of physical therapy maneuvers was determined at 1-week follow-up. Three-dimensional reconstructions of the planes of the semicircular canal cupula from histological preparations are offered as evidence for the theoretical explanation.

RESULTS

One-third of the patients met the criteria for type 2 BPPV; the remainder had typical posterior or horizontal semicircular canal involvement. Symptoms from type 2 BPPV were longer in duration yet responded favorably to physical therapy maneuvers. Upon repeat testing, 19 patients treated for posterior canalithiasis developed a slight, persistent positional downbeat nystagmus in the Dix-Hallpike position that we propose as evidence the otoconia entered the short arm of the posterior semicircular canal.

DISCUSSION AND CONCLUSIONS

Our data and 3-dimensional rendering suggest the report of vertigo, yet absent nystagmus in type 2 BPPV is from otoconia aligning with the gravitoinertial vector during provocative testing that precludes cupular stimulation. Type 2 BPPV appears to be a common and treatable form of vertigo.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A372).

[Benign paroxysmal positional vertigo : Typical and unusual clinical findings]

Benign paroxysmal positional vertigo (BPPV) is the most frequent form of vertigo seen in patients attending emergency departments. Leading symptoms are short attacks of vertigo provoked by head or body rotations. BPPV is caused by small calcium crystals, so-called otoconia, which are dislocated from the macula of the utricle mostly into the posterior semicircular canal. Free floating otoconia can move under the influence of gravity inside the semicircular canal (canalolithiasis) or adhere to the cupula (cupulolithiasis) causing displacement of the cupula. This results in positional nystagmus, whose directions and time courses are characteristic for the affected semicircular canal and the underlying cause. In recent years, however, a number of cases were reported, in which direction and times course of nystagmus differed from typical clinical findings. This may cause diagnostic problems.

Li Maneuver for geotropic horizontal canal benign paroxysmal positional vertigo (HC-BPPV) -A better choice

PURPOSE

This study aimed to retrospectively evaluate the efficacy of Li Maneuver as a repositioning maneuver for geotropic HC-BPPV, compared with Gufon Maneuver.

METHODS

Data of geotropic HC-BPPV patients treated at our department between January 2009 and January 2020 was retrospectively collected and analyzed. Enrolled cases were divided into Gufoni Group and Li Group. Follow-up results were recorded on the first, third, and seventh day after the first therapeutic maneuver.

RESULTS

A total of 254 cases were enrolled, with 87 cases in Gufoni Group, and 167 cases in Li Group. The cure rate at the first, third, and seventh days of follow-up was 62.22%, 77.01%, and 90.80% respectively for Gufoni Group, while for Li Group the number was 60.48%, 72.46%, and 89.22% respectively. Statistical analysis showed no significant difference.

CONCLUSIONS

Li Maneuver for geotropic HC-BPPV was as effective as Gufoni Maneuver but much simpler and faster. By introducing Li Maneuver, we may help physicians to treat geotropic HC-BPPV patients more willingly, which would decrease the chance of delayed treatment and ease the burden of the health-care system.

[Benign paroxysmal positional vertigo : Typical and unusual clinical findings]

Benign paroxysmal positional vertigo (BPPV) is the most frequent form of vertigo seen in patients attending emergency departments. Leading symptoms are short attacks of vertigo provoked by head or body rotations. BPPV is caused by small calcium crystals, so-called otoconia, which are dislocated from the macula of the utricle mostly into the posterior semicircular canal. Free floating otoconia can move under the influence of gravity inside the semicircular canal (canalolithiasis) or adhere to the cupula (cupulolithiasis) causing displacement of the cupula. This results in positional nystagmus, whose directions and time courses are characteristic for the affected semicircular canal and the underlying cause. In recent years, however, a number of cases were reported, in which direction and times course of nystagmus differed from typical clinical findings. This may cause diagnostic problems.

BPPV Simulation: A Powerful Tool to Understand and Optimize the Diagnostics and Treatment of all Possible Variants of BPPV

BPPV is a mechanical disorder caused by the displacement of otolith debris into the semicircular canals. The treatment involves different repositioning maneuvers to bring the debris back into the utricle. This study aims to show how dynamic simulation models based on fluid dynamics and MRI, can help to visualize and understand the movement of the debris within the canals during head movement in 3D as a function of time. The user can define the rotation angle and plane at each step of the maneuver and then the model visualizes the canal and the otoconial movement in 3D. The simulation developed also allows alteration of various parameters like the rotational head acceleration, the duration of each step of the maneuver, the initial position of the otoconial debris in the canal, the size and the number of the particles and fluid dynamics of endolymph. The clod movement is visualized in such a way that it allows a better understanding of the impact and efficacy of various liberation maneuvers and why certain maneuvers might fail when not applied properly in the clinic. The model allows simulation of multi-canal BPPV. In this paper we demonstrate the power of the model applied on the maneuvers of Semont and Yacovino when executed in different ways. The model aims to provide a visual explanation for the need of specific maneuvers for each type of BPPV. The simulator presented here can be used to test the efficacy of existing maneuvers and help in the development of new maneuvers to treat different BPPV variants.

Lateral semicircular canal-BPPV: Prospective randomized study on the efficacy of four repositioning maneuvers

INTRODUCTION

Multiple repositioning maneuvers have been described to treat lateral semi-circular canal Benign Paroxysmal Positional Vertigo (LC-BPPV) patients. In this study, we compare efficacy of four therapeutic repositioning maneuvers for LC-BPPV patients and aim to identify clinical variables associated with persistent disease.

MATERIAL AND METHODS

A prospective study was conducted at a tertiary center, between January 2017 and September 2019. Patients diagnosed with LC-BPPV were randomly treated with Gufoni or barbecue-roll maneuvers (for the geotropic variant) and Gufoni-Appiani, barbecue-roll or Zuma-e-Maia maneuvers (for the apogeotropic form). Efficacy was compared and statistical analysis was performed to find clinical factors associated with no response.

RESULTS

Forty-eight patients and 82 maneuvers were included. Female patients and right side were more commonly affected. The mean age was 67 years. Seven cases (14.6%) resulted from a canal-switch. One single maneuver resolved 23 cases (47.9%) and the success rate rose to 75% at the end of the first visit (after up to 4 maneuvers) and to 93.8% after a-week of follow-up. Success rates were significantly better with Gufoni (68%) than with barbecue roll (34.8%; p=0.021) in geotropic LC-BPPV and better with Gufoni-Appiani (71.4%) than barbecue roll and Zuma-e-Maia maneuvers (33.3%; p=0.239) in apogeotropic LC-BPPV. Higher rates of persistent disease after first visit were found with older patients, left side and apogeotropic LC-BPPV and with longer latency and duration diagnostic nystagmus.

CONCLUSION

Our study suggests that Gufoni and Gufoni-Appiani maneuvers may be the most efficacious treatment for geotropic and apogeotropic LC-BPPV, respectively, compared to barbecue-roll and Zuma-e-Maia maneuvers.

Light Cupula: To Be Or Not to Be?

Benign paroxysmal positional vertigo (BPPV) represents the most common form of positional vertigo. It is caused by dislodged otoconia that freely float in the semicircular canals (canalolithiasis) or attach to the cupula (cupulolithiasis). A cupulolithiasis-type (or a heavy cupula-type) of BPPV implicating the lateral semicircular canal (LSCC) exhibits persistent ageotropic direction-changing positional nystagmus (DCPN) in a head-roll test. However, in some cases, unlike any type of BPPV, persistent geotropic DCPN cannot be explained by any mechanisms of BPPV, and don't fit the current classifications. Recently, the notion of light cupula has been introduced to refer to the persistent geotropic DCPN. In this study, we looked at the clinical features of light cuplula and discussed the possible mechanisms and therapeutic strategies of the condition. The notion of light cupula is a helpful addition to the theory of peripheral positional vertigo and nystagmus.

Artificial intelligence-assisted prediction of preeclampsia: Development and external validation of a nationwide health insurance dataset of the BPJS Kesehatan in Indonesia

Background

We developed and validated an artificial intelligence (AI)-assisted prediction of preeclampsia applied to a nationwide health insurance dataset in Indonesia.

Methods

The BPJS Kesehatan dataset have been preprocessed using a nested case-control design into preeclampsia/eclampsia (n = 3318) and normotensive pregnant women (n = 19,883) from all women with one pregnancy. The dataset provided 95 features consisting of demographic variables and medical histories started from 24 months to event and ended by delivery as the event. Six algorithms were compared by area under the receiver operating characteristics curve (AUROC) with a subgroup analysis by time to the event. We compared our model to similar prediction models from systematically reviewed studies. In addition, we conducted a text mining analysis based on natural language processing techniques to interpret our modeling results.

Findings

The best model consisted of 17 predictors extracted by a random forest algorithm. Nine∼12 months to the event was the period that had the best AUROC in external validation by either geographical (0.88, 95% confidence interval (CI) 0.88–0.89) or temporal split (0.86, 95% CI 0.85–0.86). We compared this model to prediction models in seven studies from 869 records in PUBMED, EMBASE, and SCOPUS. This model outperformed the previous models in terms of the precision, sensitivity, and specificity in all validation sets.

Interpretation

Our low-cost model improved preliminary prediction to decide pregnant women that will be predicted by the models with high specificity and advanced predictors.

Funding

This work was supported by grant no. MOST108-2221-E-038-018 from the Ministry of Science and Technology of Taiwan.

Adverse effects of semicircular circle angles variation on Epley repositioning procedure: a study on reconstruction of Micro-CT images 3D

Background: For patients with posterior semicircular canal (PSC) BPPV, Epley re-position maneuver and some improvement methods are the most efficient treatment methods. But there were still 9.43% patients who were not benefit from Epley re-position maneuver.Objective: To measure the angles of semicircular canals and evaluate its effect on Epley maneuver.Methods: Fifteen skull specimens, containing 30 temporal bone specimens were included. After Micro-CT scanning, 3D reconstruction was loaded with the CT image. The angles between each semicircular canal and each standard skull plane were measured. Furthermore, the angles' effect on Epley maneuver was evaluated according to the three-dimension (3D) model.Results: Angles of PSC plane: Frankfurt plane was 71.54 ± 6.51, sagittal plane was 53.77 ± 5.36°, and the coronal plane was 43.33 ± 3.56°. Angles between PSC and the sagittal plane of skulls had an adverse effect on Epley maneuver, when it was less than 45°.Conclusion: 1. Variation could be found in angles between the semicircular canals and the standard planes of skulls, which meant variation of semicircular canals' location existing in skulls. 2. The variation of angles between PSC and sagittal plane could have an adverse effect on the Epley maneuver when the angle was less than 45°, which may cause the Epley maneuver to be invalid.

[Clinical and psychological features in patients with incident and recurrent cases of benign paroxysmal positional vertigo]

OBJECTIVE

To assess the clinical and psychological features in patients with incident and recurrent posterior canal BPPV.

PATIENTS AND METHODS

The study included 47 patients (mean age 49.1±10.9 years; 12.8% of men and 87.2% of women) with idiopathic BPPV, posterior canal. According to the anamnesis, the patients were divided into two groups: 27 (57.4%) patients with incident BPPV (iBPPV) and 20 (42.6%) patients with recurrent BPPV (rBPPV). All patients were treated with repositioning Epley and/or Semont maneuvers until resolution of canalolithiasis. After that, clinical and psychological testing was immediately carried out, including short version of Vertigo Symptom Scale (VSS), Dizziness Handicap Inventory (DHI), Visual analogue scale (VAS) for fear of vertigo spells, Depersonalization-Derealization Inventory (DDI), Social Readjustment Rating Scale (SRRS) of Holmes and Rahe, Anxiety Sensitivity Index (ASI), Generalized Anxiety Disorder Scale (GAD-7) and Patient Health Questionnaire (PHQ).

RESULTS

Patients with rBPPV compared with iBPPV had more severe symptoms of dizziness according to DHI (p=0.02) due to a functional and emotional subscales, as well as a more pronounced feeling of fear according to VAS (p=0.01). The data obtained on the remaining scales and questionnaires did not show statistically significant differences between the groups. The revealed results may indicate a greater predisposition of patients with rBPPV to the development of a special kind of mental disorders - functional dizziness or persistent postural-perceptual dizziness, which requires additional study and development of preventive measures.

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.

Can the bending forward test be used to detect a diseased anterior semi-circular canal in patients with chronic vestibular multi-canalicular canalithiasis (BPPV)?

Introduction: Patients with chronic vestibular multi-canalicular canalithiasis (CVMCC) can have serious morbidities, for example, musculoskeletal pain, dizziness, fatigue, and cognitive difficulties. Involvement of the anterior semi-circular canal (SCC) is common in CVMCC. A mono-canalicular diseased anterior SCC is rare.Aim: To examine if the Bending forward test can be used to detect a diseased anterior semi-circular canal in patients with CVMCC.Material and Methods: Prospective consecutive observational cohort study in patients with relapse of an earlier successfully treated chronic CVMCC, where 16 patients have a diseased anterior SCC, 11 without any involvement of the anterior SCC, and 15 healthy controls. Patients are tested in sitting and in bending forward position. The difference in downwards directed nystagmus count and slow phase velocity in the two test positions AND reported movement illusion are the main outcome.Results: The sensitivity of the Bending forward-test is 81%; the specificity 91%. Five of the healthy controls have positional nystagmus without movement illusion. This is interpreted as cupulolithiasis. Positional nystagmus with movement illusion is interpreted as canalithiasis.Conclusions: Bending forward-test is a valuable test. Only positional nystagmus accompanied by a movement illusion, that is canalithiasis, is of clinical relevance.Significance: These findings may assist in diagnosing compound musculoskeletal disorders.

Use of the Bárány Society criteria to diagnose benign paroxysmal positional vertigo

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder affecting about 20% of dizzy patients. Early diagnosis and treatment can improve the quality of life for patients.

OBJECTIVE

We reviewed the classifications of different subtypes of benign paroxysmal positional vertigo and the problems we encountered using the diagnostic criteria of the Bárány Society.

METHODS

Both the Dix-Hallpike maneuver and supine roll test were performed on 568 patients, and diagnoses were made based on patient history and the type of provoked nystagmus (if any). Next, the numbers of patients with each subtype and other parameters, including age and sex, were analyzed.

RESULTS

Posterior semicircular canal BPPV (pc-BPPV) accounted for the largest proportion, followed by horizontal semicircular canal BPPV (hc-BPPV). Both anterior canal BPPV and multiple canal lithiasis BPPV were rare, and no patient was diagnosed with cupulolithiasis of the posterior canal.

CONCLUSIONS

pc-BPPV, hc-BPPV, and cupulolithiasis of the horizontal canal (hc-BPPV-cu) were the three major subtypes that could be definitively diagnosed, whereas the diagnoses of possible benign paroxysmal positional vertigo (pBPPV) and probable benign paroxysmal positional vertigo [spontaneously resolved] (pBPPVsr) require further investigation, with special attention being paid to appropriate differentiation and repositioning maneuvers.

Approach to residual dizziness after successfully treated benign paroxysmal positional vertigo: effect of a polyphenol compound supplementation

Purpose

To assess if a polyphenol compound supplementation (Vertigoval^®) could improve residual dizziness earlier after benign paroxysmal positional vertigo (BPPV) and relieve patients from this disabling symptomatology.

Methods

In this prospective, multicentric study, 127 patients were randomized in the treatment group (TG), who received a 60-day supplementation, while 131 patients were randomized in the control group (CG), who did not receive any medication. The dizziness handicap inventory (DHI) score, static posturography, and the visual analog scale (VAS) for both dizziness (D-VAS) and nausea/vomit (N/V-VAS) were used as measures of outcome at baseline and after 30 and 60 days. Patients were asked about efficacy and tolerance to the treatment. Side effects were examined.

Results

A statistically significant greater decrease was established in the TG for DHI, D-VAS, and N/V-VAS compared to the CG. On the other hand, static posturography did not show statistical differences between the two groups, though a better clinical improvement after 60-day supplementation was shown in the TG in comparison to the CG. We counted mild side effects in only 2 patients. Most patients reported an excellent or good efficacy and tolerance to the treatment.

Conclusion

Residual dizziness is a frequent condition of unknown origin that manifests as persistent disabling imbalance after successful repositioning maneuvers for BPPV. The decreasing postural control can affect the quality of life, contributing to falling and psychological problems. The supplementation with the polyphenol compound used in our study is safe, manageable, and appeared to be able to reduce subjective symptoms and improve instability earlier, decreasing the risk of potential complications.

Classification of vestibular signs and examination techniques: Nystagmus and nystagmus-like movements

This paper presents a classification and definitions for types of nystagmus and other oscillatory eye movements relevant to evaluation of patients with vestibular and neurological disorders, formulated by the Classification Committee of the Bárány Society, to facilitate identification and communication for research and clinical care. Terminology surrounding the numerous attributes and influencing factors necessary to characterize nystagmus are outlined and defined. The classification first organizes the complex nomenclature of nystagmus around phenomenology, while also considering knowledge of anatomy, pathophysiology, and etiology. Nystagmus is distinguished from various other nystagmus-like movements including saccadic intrusions and oscillations.

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Immediate efficacy of Gufoni maneuver for horizontal canal benign paroxysmal positional vertigo (HC-BPPV): a meta-analysis

OBJECTIVE

This meta-analysis aims to systematically measure the immediate efficacy of the Gufoni maneuver for horizontal canal benign paroxysmal positional vertigo (HC-BPPV).

METHODS

A extensive search electronic databases, including PubMed, Embase, Web of Science and Cochrane library, were searched until to September 1, 2018 for relevant articles. We selected only randomized clinical trials studying with treatment of HC-BPPV employ by the Gufoni maneuver.

RESULTS

Five randomized clinical trials were included in the current meta-analysis with a total of 714 HC-BPPV patients. The meta-analysis revealed that Gufoni maneuver had a higher immediate recovery rate than sham maneuver in treatment of HC-BPPV (risk ratio = 2.68, 95% CI, 1.54-4.65, p < 0.01). No difference was observed in immediate recovery rate between Gufoni maneuver and other maneuvers (risk ratio = 1.18, 95% CI, 0.99-1.41, p = 0.06). And Gufoni maneuver had a similar otolith switch rate with other maneuvers (risk ratio = 2.13, 95% CI, 0.56-8.07, p = 0.27).

CONCLUSION

Gufoni maneuver has a satisfactory immediate efficacy for HC-BPPV and does not increase otolith switch rate.

Group-level cortical and muscular connectivity during perturbations to walking and standing balance

Maintaining balance is a complex process requiring multisensory processing and coordinated muscle activation. Previous studies have indicated that the cortex is directly involved in balance control, but less information is known about cortical flow of signals for balance. We studied source-localized electrocortical effective connectivity dynamics of healthy young subjects (29 subjects: 14 male and 15 female) walking and standing with both visual and physical perturbations to their balance. The goal of this study was to quantify differences in group-level corticomuscular connectivity responses to sensorimotor perturbations during walking and standing. We hypothesized that perturbed visual input during balance would transiently decrease connectivity between occipital and parietal areas due to disruptive visual input during sensory processing. We also hypothesized that physical pull perturbations would increase cortical connections to central sensorimotor areas because of higher sensorimotor integration demands. Our findings show decreased occipito-parietal connectivity during visual rotations and widespread increases in connectivity during pull perturbations focused on central areas, as expected. We also found evidence for communication from cortex to muscles during perturbed balance. These results show that sensorimotor perturbations to balance alter cortical networks and can be quantified using effective connectivity estimation.

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.

Benign positional vertigo, its diagnosis, treatment and mimics

The diagnosis of benign positional vertigo (BPV) relies on a history of episodic positional vertigo and a distinctive pattern of nystagmus during provocative positional testing. The direction of the induced nystagmus is specific to the affected canal and the velocity profile reflects the underlying mechanism of canalithiasis (free-floating otoconia within the canal duct) or cupulolithiasis (otoconia adherent to the cupula). We review current theories on the pathophysiology of BPV, the clinical history and examination underlying its diagnosis, and recommended repositioning manoeuvres for each of the BPV subtypes. Disorders other than BPV which may present with a similar history and/or positional nystagmus are discussed.

Increased Risk of Benign Paroxysmal Positional Vertigo in Patients With Non-Apnea Sleep Disorders: A Nationwide, Population-Based Cohort Study

STUDY OBJECTIVES

To investigate the association between non-apnea sleep disorders (NSD) and subsequent benign paroxysmal positional vertigo (BPPV) risk.

METHODS

This retrospective cohort study was conducted using the Taiwan National Health Insurance Research Database from 2000 to 2013. We established an NSD group (n = 24,624) and an age-, sex- and index year-matched comparison group (n = 98,496). The primary outcome was the occurrence of BPPV. The incidence rates of BPPV in the two cohorts were compared with a 14-year follow-up. Cox proportional hazard regression analysis was used to evaluate the effects of NSD on BPPV risk.

RESULTS

The incidence rate of BPPV was 43.33 per 100,000 person-years for the NSD cohort and 29.33 per 100,000 person-years for the comparison cohort. NSD significantly increased the risk of BPPV (adjusted hazard ratio [HR] = 2.487; 95% confidence interval = 1.996-3.099, P < .001). Subgroup analysis revealed that NSD increase the risk of development of BPPV by 2.357- to 3.658-fold in patients with hypertension, diabetes mellitus, chronic obstructive pulmonary disease, and hyperlipidemia. Furthermore, when comparing different types of NSD, chronic insomnia carries the highest risk of BPPV (adjusted HR = 3.563), followed by organic sleep disorders (adjusted HR = 2.763), sleep disturbance (adjusted HR = 2.506), and acute insomnia (adjusted HR = 2.237).

CONCLUSIONS

We demonstrate that NSD are associated with an increased risk of BPPV. Relative to other types of NSD, patients with chronic insomnia are at the highest risk for development of BPPV.

Benign paroxysmal positional vertigo in the elderly: current insights

Balance disorders, unsteadiness, dizziness and vertigo in the elderly are a significant health problem, needing appropriate treatment. One third of elderly patients with vertigo were diagnosed with benign paroxysmal positional vertigo (BPPV), the most common cause of dizziness in both primary care specialist Neurology and Ear Nose Throat settings. BPPV presents a specific paroxysmal positional nystagmus which can be obtained using the appropriate diagnostic positional test and can be treated effectively using specific therapeutic maneuvers. This review presents current insights into the diagnostic, pathogenetic and therapeutic aspects of BPPV in the elderly. BPPV in older patients does not differ significantly from BPPV in younger patients, with regard to pathogenesis, diagnosis and treatment. However, in older patients, its prevalence is higher and it responds less effectively to treatment, having a tendency for recurrence. Specific issues which should be considered in the elderly are: 1) difficulty in obtaining an accurate history; 2) difficulty in performing the diagnostic and therapeutic maneuvers, which should be executed with slow and gentle movements and extremely cautiously to avoid any vascular or orthopedic complications; and 3) the relation between BPPV and falls.

Benign paroxysmal positional vertigo in children

OBJECTIVE

To describe the clinical features of benign paroxysmal positional vertigo (BPPV) in children.

DESIGN

A retrospective study.

SETTING

Six children diagnosed with BPPV between March 2014 and March 2015 were retrospectively evaluated. BPPV was diagnosed using the Dix-Hallpike and supine roll tests and treated with either the modified Epley particle repositioning procedure or Lempert or Gufoni manoeuvre. Follow-up was performed at 1-week intervals until vertigo and nystagmus disappeared during positional testing.

PARTICIPANTS

A total of six children were followed up for a period of 10-22 months.

MAIN OUTCOME MEASURES

Clinical features such as history, nystagmus and symptoms of vertigo, dizziness and nausea.

RESULTS

Six children were diagnosed with BPPV using positional testing and treated with the modified Epley or Lempert/Gufoni particle repositioning procedures. Four children were diagnosed with posterior canal BPPV, while the remaining two were diagnosed with horizontal canal BPPV. One girl reported a history of head trauma, one girl had a family history of vertigo, and one boy reported hearing loss in the same ear as that affected by BPPV. Overall, 83.33% of children (5/6) were completely relieved of vertigo following one treatment session. The remaining child was asymptomatic after two sessions. No child reported relapse of vertigo during the follow-up period.

CONCLUSIONS

BPPV can be diagnosed accurately by taking a detailed medical history and by use of positional testing. BPPV in children can be successfully identified and treated.

Efficacy of Repositioning Therapy in Patients With Benign Paroxysmal Positional Vertigo and Preexisting Central Neurologic Disorders

With the exception of migraines, benign paroxysmal positional vertigo (BPPV) in patients with preexisting central neurologic disorders (CND) is rarely discussed in the literature. Demographic features of this patient group and the efficacy of repositioning therapy are still unknown. We hypothesized that a CND may alter the function of the central vestibular pathway, thus changing the pattern of BPPV and outcomes of repositioning. In this study, we enrolled 93 consecutive idiopathic BPPV patients and categorized them into two groups according to the presence or absence of a CND. In our series, 31.2% of BPPV cases had a CND. The most common associated CNDs were cerebrovascular disease and migraines. The two groups showed similar age distributions, canal involvement, success rates of repositioning, and cycles of treatment used to achieve complete resolution. The major differences were the proportion of females (89.7%) and a right-side predominance (75.9%) in the CND group. There was a trend of more residual dizziness (RD) after successful repositioning in the CND group, but the difference was not significant. The reason for the female and right-side predominance in the CND group is unclear. We concluded that the efficacy of repositioning therapy was excellent (with a success rate of 80.6% with one cycle and 93.5% within two cycles of treatment) for BPPV with or without a preexisting CND. Clinicians are encouraged to diagnose and treat BPPV in patients with a preexisting CND as early as possible to improve patients' quality of life, avoid complications, and reduce medical costs.

Analysis of effect of 1α-hydroxyvitamin D3 on benign paroxysmal positional vertigo and risk factors

The purpose of this study was to investigate the curative effect of 1α-hydroxyvitamin D3 on the benign paroxysmal positional vertigo (BPPV). Fifty BPPV patients diagnosed in the ENT Department of Anzhen Hospital from October 2015 to December 2016 were randomly selected as the treatment group, and treated with 0.25 µg 1α-hydroxyvitamin D3 once per day, in addition to the routine diagnosis and treatment. Moreover, 50 BPPV patients in the same period were selected as the control group, and received the routine diagnosis and treatment. The detection results of bone mineral density (BMD) t-value, vitamin D3 and bone metabolic markers before and after treatment were compared, and statistical analysis was performed on the results. There were no differences in the general data between treatment group and control group. There were no statistically significant differences in the BMD and age distribution of males and females between treatment group and control group (P>0.05). The BMD of male BPPV patients in each age group in the treatment group was significantly increased after treatment, and the difference was statistically significant (P<0.05). Although the BMD of male BPPV patients in each age group in control group was somewhat increased after treatment, the difference was not statistically significant (P>0.05). The BMD of female BPPV patients in each age group in treatment group was increased after treatment, and the difference was statistically significant (P<0.05). Similarly, although the BMD of female BPPV patients in each age group in control group was somewhat increased after treatment, the difference was not statistically significant (P>0.05). The average BMD of female BPPV patients in each age group was significantly lower than that of male patients, and the difference was statistically significant (P<0.05) (Table II). The BMD t-value of patients in treatment group showed a decreasing trend with the increase of age (Fig. 1). The levels of 25-hydroxyvitamin D3 and bone metabolic markers in treatment group were significantly improved compared with those before treatment (P<0.05). Multivariate Logistic regression analysis was performed to identify whether the treatment of BPPV was effective or not as a dependent variable, and six items, including the sex (female), hypertension, diabetes mellitus, age (>50 years), 25-hydroxyvitamin D3 and osteopenia/osteoporosis, as the independent variables, and the results suggested that the level of 25-hydroxyvitamin D3 and osteopenia/osteoporosis are the clinical features of whether the BPPV treatment is effective (P<0.05). The results showed that the treatment of BPPV with 1α-hydroxyvitamin D3 can effectively improve the symptoms of patients, and the level of vitamin D3 and the occurrence of osteopenia/osteoporosis are the clinical indexes of whether the BPPV treatment is effective.