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Kim JM, Lee SH, Kim HJ, Kim JS. Less talked variants of benign paroxysmal positional vertigo. J Neurol Sci 2022; 442:120440. [PMID: 36244097 DOI: 10.1016/j.jns.2022.120440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 09/18/2022] [Accepted: 09/25/2022] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Jae-Myung Kim
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Seung-Han Lee
- Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Hyo-Jung Kim
- Research Administration Team, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Helminski JO. Case report: Atypical patterns of nystagmus suggest posterior canal cupulolithiasis and short-arm canalithiasis. Front Neurol 2022; 13:982191. [PMID: 36299265 PMCID: PMC9588913 DOI: 10.3389/fneur.2022.982191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/26/2022] [Indexed: 12/03/2022] Open
Abstract
Background Atypical posterior canal (PC) positional nystagmus may be due to the changes in cupular response dynamics from cupulolithiasis (cu), canalithiasis of the short arm (ca-sa), or a partial/complete obstruction—jam. Factors that change the dynamics are the position of the head in the pitch plane, individual variability in the location of the PC attachment to the utricle and the position of the cupula within the ampulla, and the location of debris within the short arm and on the cupula. The clinical presentation of PC-BPPV-cu is DBN with torsion towards the contralateral side in the DH positions and SHHP or no nystagmus in the ipsilateral DH position and no nystagmus upon return to sitting from each position. The clinical presentation of PC-BPPV-ca-sa is no nystagmus in the DH position and upbeat nystagmus (UBN) with torsion lateralized to the involved side upon return to sitting from each position. Case description A 68-year-old woman, diagnosed with BPPV, presented with DBN associated with vertigo in both DH positions and without nystagmus or symptoms on sitting up. In the straight head hanging position (SHHP), the findings of a transient burst of UBN with left torsion associated with vertigo suggested ipsicanal conversion from the left PC-BPPV-cu to canalithiasis. Treatment included a modified canalith repositioning procedure (CRP), which resulted in complete resolution. BPPV recurred 17 days later. Clinical presentation of BPPV included no nystagmus/symptoms in both the contralateral DH position and SHHP, DBN in the ipsilateral DH position without symptoms, and UBN with left torsion associated with severe truncal retropulsion and nausea on sitting up from provoking position. The findings suggested the left PC-BPPV-cu-sa and PC-BPPV-ca-sa. Treatment included neck extension, a modified CRP, and demi-Semont before complete resolution. Conclusion An understanding of the biomechanics of the vestibular system is necessary to differentially diagnose atypical PC-BPPV. DH test (DHT) findings suggest that PC-BPPV-cu presents with DBN or no nystagmus in one or two DH positions and sometimes SHHP and without nystagmus or no reversal/reversal of nystagmus on sitting up. The findings suggest PC-BPPV-ca-sa has no nystagmus in DH positions or DBN in the ipsilateral DH position and UBN with torsion lateralized to the involved side on sitting up.
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RE: BENIGN PAROXYSMAL POSITIONAL VERTIGO: CANAL SWITCHING AFFECTING ALL CANALS DURING A SINGLE SESSION. Otol Neurotol 2022; 43:e694-e695. [PMID: 35761467 DOI: 10.1097/mao.0000000000003542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ramos BF, Cal R, Mangabeira Albernaz PL, Zuma e Maia F. Vertical “pseudospontaneous” nystagmus in a patient with posterior canal BPPV: case report. ACTA OTO-LARYNGOLOGICA CASE REPORTS 2021. [DOI: 10.1080/23772484.2021.2008800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Bernardo Faria Ramos
- Department of Otorhinolaryngology, Federal University of Espirito Santo (UFES), Vitoria, Brazil
| | - Renato Cal
- Department of Otorhinolaryngology, University Center of Para (CESUPA), Belem, Brazil
| | | | - Francisco Zuma e Maia
- Department of Otorhinolaryngology, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
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Castellucci A, Martellucci S, Malara P, Botti C, Del Vecchio V, Brandolini C, Ferri GG, Ghidini A, Armato E. Possible pathomechanisms accounting for both sound/pressure-induced eye movements and video head impulse test data in superior canal dehiscence. Acta Otolaryngol 2021; 141:749-753. [PMID: 34236943 DOI: 10.1080/00016489.2021.1944664] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Andrea Castellucci
- ENT Unit, Department of Surgery, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Pasquale Malara
- Audiology and Vestibology Service, Centromedico, Bellinzona, Switzerland
| | - Cecilia Botti
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Valeria Del Vecchio
- UOC Audiology and Vestibology, University Hospital Federico II, Naples, Italy
| | - Cristina Brandolini
- ENT and Audiology Unit, DIMES, S.Orsola - Malpighi University Hospital, Bologna, Italy
| | - Gian Gaetano Ferri
- ENT and Audiology Unit, DIMES, S.Orsola - Malpighi University Hospital, Bologna, Italy
| | - Angelo Ghidini
- ENT Unit, Department of Surgery, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Enrico Armato
- ENT Unit, SS Giovanni e Paolo Hospital, Venice, Italy
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Which Inner Ear Disorders Lie Behind a Selective Posterior Semicircular Canal Hypofunction on Video Head Impulse Test? Otol Neurotol 2021; 42:573-584. [PMID: 33710996 DOI: 10.1097/mao.0000000000002995] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess all different patterns of associated abnormalities on audiometry, bithermal caloric test (BCT) and cervical/ocular vestibular-evoked myogenic potentials (VEMPs) to air/bone-conduction in patients with selective posterior semicircular canal (PSC) hypofunction and to correlate them with underlying disorders. STUDY DESIGN Retrospective review. SETTING Tertiary referral center. PATIENTS 51 patients (23 men, 28 women, mean age 57.5 yr) with isolated PSC deficit (one bilateral). INTERVENTIONS Correlation with instrumental data and underlying diagnoses. MAIN OUTCOME MEASURES Video-oculographic findings, objective measurements on audiometry, BCT, VEMPs and video-head impulse test (vHIT). RESULTS Ongoing or previous acute vestibular loss (AVL) was diagnosed in 13 patients (25.5%, 3 inferior vestibular neuritis, 10 AVL with sudden sensorineural hearing loss [SSNHL]), Meniere's disease (MD) in 12 (23.5%), cerebellopontine angle (CPA) lesion in 9 (17.6%), various causes in 7 (13.7%), benign paroxysmal positional vertigo (BPPV) involving the non-ampullary arm of PSC in 5 cases (9.8%) whereas unknown pathology in 5 (9.8%). Involvement of at least one additional receptor besides PSC was seen in 89.8% of cases. Cochlear involvement was diagnosed in 74.5% with pure-tone average significantly greater in patients with AVL+SSNHL (p < 0.05). Overall involvement of labyrinthine receptors or afferents was highest in patients with AVL+SSNHL (p < 0.01), MD and CPA lesions (p < 0.05). CONCLUSIONS Isolated loss of PSC function on vHIT is mostly accompanied by additional labyrinthine deficits that could only be identified through an accurate instrumental evaluation. Assessment of all receptors and afferents should be always pursued to identify the lesion site and better understand the underlying pathophysiological mechanisms.
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Castellucci A, Malara P, Martellucci S, Delmonte S, Ghidini A. Fluctuating Posterior Canal Function in Benign Paroxysmal Positional Vertigo Depending on How and Where Otoconia Are Disposed. Otol Neurotol 2021; 42:e193-e198. [PMID: 33273306 DOI: 10.1097/mao.0000000000002913] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Though fluctuations in vestibular function represent a common finding in Menière's disease, we describe how benign paroxysmal positional vertigo (BPPV) may result in fluctuations of vestibulo-ocular reflex for the involved canal depending on the disposition of otoliths. PATIENT A 54-year-old woman suffering from refractory posterior canal (PC)-BPPV resulting in fluctuating PC function. INTERVENTIONS Diagnostic evaluation and rehabilitative treatment for BPPV involving the affected PC. MAIN OUTCOME MEASURES Video-Frenzel and video-head impulse test (vHIT) findings before and after canalith repositioning procedures for PC-BPPV. RESULTS BPPV involving the nonampullary arm of right PC was diagnosed based on presenting positional downbeat nystagmus and selective right PC hypofunction at the vHIT. During physical treatment, nystagmus first became positional paroxysmal upbeat likely due to a shift of debris into the ampullary arm of the canal, then turned to spontaneous downbeat nystagmus consistently with a plug effect exerted by particles entrapped within the nonampullary arm of PC and finally receded proving an otoliths fall within the utriculus. Simultaneously, vHIT documented fluctuations for right PC vestibulo-ocular reflex gain as it first increased to normal values, then severely declined and finally normalized, respectively. High-resolution computed tomography scan detected ipsilateral superior canal dehiscence. CONCLUSIONS In accordance with recently reported vHIT findings in different types of BPPV, fluctuation of PC function could be likely explained by the effect of particles on cupular dynamic responses depending on the portion of the canal gradually involved. Superior canal dehiscence may have played a role facilitating otoliths mobilization by reducing labyrinthine impedance.
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Affiliation(s)
- Andrea Castellucci
- ENT Unit, Department of Surgery, Azienda USL - IRCCS, Reggio Emilia, Italy
| | - Pasquale Malara
- Audiology and Vestibology Service, Centromedico, Bellinzona, Switzerland
| | | | - Silvia Delmonte
- ENT Unit, Department of Surgery, Azienda USL - IRCCS, Reggio Emilia, Italy
| | - Angelo Ghidini
- ENT Unit, Department of Surgery, Azienda USL - IRCCS, Reggio Emilia, Italy
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Califano L, Iannella R, Mazzone S, Salafia F, Melillo MG. The Video Head Impulse Test in the acute stage of posterior canal benign paroxysmal positional vertigo. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2021; 41:69-76. [PMID: 33746225 PMCID: PMC7982752 DOI: 10.14639/0392-100x-n1033] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 11/02/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Study the high-frequency vestibulo-oculomotor reflex in posterior canal benign paroxysmal positional vertigo (BPPV) through Video Head Impulse Test (vHIT). METHODS 150 patients suffering for the first time from posterior canal BPPV were studied. Posterior canal vestibulo ocular reflex (VOR) gain was analysed through stimulations in right anterior-left posterior and left anterior-right posterior planes before treatment, immediately after resolution of the acute stage and one month later. Results were compared with a group of 100 healthy individuals. RESULTS No significant difference between the study the control groups was observed, except for normalised asymmetry ratio of the posterior canal which was significantly higher in the study group. VOR gains of both affected posterior canals and contralateral healthy posterior canals were not significantly correlated with the VOR gain of ipsilateral and contralateral anterior canals. CONCLUSIONS vHIT does not seem to represent an essential tool to study typical posterior canal BPPV in patients affected by this disease for the first time. Different results might be expected in relapsing forms, non-responsive forms, long lasting forms, or atypical variants in which major damage could be provoked by the persistence of otoconia in the canal or by its complete or partial jam.
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Affiliation(s)
- Luigi Califano
- San Pio Hospital, Department of Audiology and Phoniatrics, Benevento, Italy
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Castellucci A, Malara P, Martellucci S, Botti C, Delmonte S, Quaglieri S, Rebecchi E, Armato E, Ralli M, Manfrin ML, Ghidini A, Asprella Libonati G. Feasibility of Using the Video-Head Impulse Test to Detect the Involved Canal in Benign Paroxysmal Positional Vertigo Presenting With Positional Downbeat Nystagmus. Front Neurol 2020; 11:578588. [PMID: 33178119 PMCID: PMC7593380 DOI: 10.3389/fneur.2020.578588] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/07/2020] [Indexed: 12/19/2022] Open
Abstract
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.
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Affiliation(s)
- Andrea Castellucci
- ENT Unit, Department of Surgery, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Pasquale Malara
- Audiology and Vestibology Service, "Centromedico Bellinzona", Bellinzona, Switzerland
| | | | - Cecilia Botti
- ENT Unit, Department of Surgery, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy.,PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Silvia Delmonte
- ENT Unit, Department of Surgery, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Silvia Quaglieri
- ENT Unit, Policlinico San Matteo Fondazione (IRCCS), Pavia, Italy
| | | | - Enrico Armato
- ENT Unit, "SS Giovanni e Paolo" Hospital, Venice, Italy
| | - Massimo Ralli
- Head and Neck Department, ENT Clinic, Policlinico Umberto I, Rome, Italy.,Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | | | - Angelo Ghidini
- ENT Unit, Department of Surgery, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
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Shupak A, Falah R, Kaminer M. Functional Integrity of the Inferior Vestibular Nerve and Posterior Canal BPPV. Front Neurol 2020; 11:894. [PMID: 32982924 PMCID: PMC7479309 DOI: 10.3389/fneur.2020.00894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 07/13/2020] [Indexed: 11/13/2022] Open
Abstract
The functional integrity of the inferior vestibular nerve (IVN) may be evaluated by the cervical vestibular evoked myogenic potential (cVEMP) response, which requires signal transmission via the nerve. As functional integrity of the IVN innervating the posterior semicircular canal is required to produce the typical positioning vertigo and nystagmus characterizing posterior canal benign paroxysmal positional vertigo (PCBPPV), we hypothesized that normal cVEMPs would be found in most PCBPPV patients. Twenty-four PCBPPV patients participated in a prospective cohort study. All were treated by canal repositioning maneuver and had air-conduction cVEMP and videonystagmography (VNG). Follow-up evaluations including history and otoneurological bedside examination were carried out 1, 3, 6, and 12 months after the initial treatment. At the last follow-up, the patients filled the Dizziness Handicap Inventory (DHI) questionnaire. Normal cVEMPs were recorded in 19 (79%) and were absent in 5 (21%) of the subjects. The average DHI in the patients with normal cVEMP was 16.42 ± 17.99 vs. 0.4 ± 0.89 among those with pathological cVEMP (p < 0.04, Mann-Whitney test). Thirteen (54%) patients experienced recurrent PCBPPV (rPCBPPV). The average DHI score was significantly higher among patients having recurrence (22.15 ± 18.61) when compared to those with complete cure (2.36 ± 5.98; p < 0.003, Mann-Whitney test). Ten (77%) of the subjects with rPCBPPV had normal and 3 (23%) had pathological cVEMP as compared to 9 (82%) and 2 (18%) subjects in the non-recurrent (nrPCBPPV) group (Fisher's exact test-not significant). cVEMP p13 and n23 wave latencies and amplitudes, inter-aural differences in p13-n23 peak-to-peak amplitudes, and response thresholds did not differ between the groups. No differences were found between the rPCBBPV and nrPCBBPV groups in VNG caloric lateralization and directional preponderance values. We have found that in most cases, PCBPPV symptoms and signs are associated with normal cVEMP response supporting the role of IVN functional integrity. The absent cVEMPs in the minority of patients, although having similar clinical presentation, raise the possibility that the ipsilateral saccule is affected by the same pathology causing degeneration of the utricle macula. Alternatively, lacking inhibitory stimuli from the involved ipsilateral utricle or partial degeneration of the IVN and ganglion could explain the diminished cVEMP response. Clinical Trial Registration: The study was registered in ClinicalTrials.gov Internet site (study ID-NCT01004913; https://clinicaltrials.gov/ct2/show/NCT01004913?cond=BPPV&cntry=IL&draw=2&rank=3).
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Affiliation(s)
- Avi Shupak
- Unit of Otoneurology, Lin Medical Center, Haifa, Israel.,Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel.,Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel
| | - Rohi Falah
- Unit of Otoneurology, Lin Medical Center, Haifa, Israel.,Department of Otolaryngology Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel
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Clinical implications of posterior semicircular canal function in idiopathic sudden sensorineural hearing loss. Sci Rep 2020; 10:8313. [PMID: 32433568 PMCID: PMC7239936 DOI: 10.1038/s41598-020-65294-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 04/15/2020] [Indexed: 01/09/2023] Open
Abstract
Predicting hearing outcomes in idiopathic sudden sensorineural hearing loss (ISSNHL) is still challenging. We hypothesized that assessment of the semicircular canal (SCC) function via the video head impulse test (vHIT) might provide prognostic information. The medical records of patients diagnosed with ISSNHL from January 2015 to December 2018 were retrospectively reviewed. The prognostic values of the vHIT and other previously known factors in predicting hearing recovery were analyzed using a logistic regression model. A total of 148 patients with normal contra-lesional hearing were analyzed. Fifty-seven patients exhibited low gain (<0.7) on the vHIT in at least one SCC, more than the number of patients complaining of dizziness. Multivariable analysis revealed that non-recovery of normal hearing was associated with older age (OR 1.040), worse canal paresis on the caloric test (OR 1.023), worse initial hearing thresholds (OR 1.045) and abnormal vHIT result in the posterior SCC (OR 3.670). Low vHIT gain in the posterior SCC had specificity of 94.4% and positive predictive value of 85.7% in predicting non-recovery of normal hearing. In conclusion, abnormal vHIT gain in the posterior SCC appears to be a specific prognostic factor for incomplete hearing recovery in ISSNHL.
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