Apogeotropic variant of lateral semicircular canal benign paroxysmal positional vertigo: is there a correlation between clinical findings, underlying pathophysiologic mechanisms and the effectiveness of repositioning maneuvers?

The spatial orientation of crista ampullaris: implications for BPPV diagnosis and treatment

Objective

This study aimed to provide a comprehensive understanding of the spatial orientation of the crista ampullaris within the inner ear and its implications for the diagnosis and management of benign paroxysmal positional vertigo (BPPV).

Methods

Using high-resolution MRI scans of 55 normal inner ears, 3D models of the semicircular canals were segmented. These were complemented by detailed membrane labyrinth models from micro-CT scans of human temporal bones, accessed via the Comparative Ear Bank (www.earbank.org). A statistical shape model of inner ears and eyeballs was established, and a standardized 3D spatial coordinate system was created. The horizontal plane was defined using the top of the common crus and the bottom of the eyeballs. This calibrated reference system allowed for precise quantification of crista ampullaris orientations by calculating angles between the defined crista planes and coordinate planes.

Results

The plane of the ampulla and the corresponding semicircular canal plane are nearly perpendicular to each other. In the upright position, the posterior semicircular canal crista ampullaris formed an angle of 48.9° with the horizontal plane. The relative orientations of the crista ampullaris of the lateral and superior canals were also defined. Furthermore, we identified "zero-point planes" representing crista orientations perpendicular to gravity, which resulted in minimal ampullary stimulation. A 6.2° tilt to the left in the supine position resulted in the plane of the left lateral semicircular canal crista ampullaris being parallel to the direction of gravity.

Conclusion

This study elucidates the precise spatial orientation of the crista ampullaris, thereby providing an anatomical basis for understanding BPPV pathophysiology and improving the accuracy of diagnostic and therapeutic maneuvers. The findings have the potential to significantly enhance the management of BPPV and other inner ear disorders.

Treatment Efficacy of Forced Prolonged Position After Cupulolith Repositioning Maneuver in Apogeotropic HSCC BPPV

OBJECTIVES

To evaluate the therapeutic efficacy of the forced prolonged position (FPP) in patients with horizontal semicircular canal (HSCC) cupulolithiasis in whom the cupulolith repositioning maneuver (CuRM) failed.

METHODS

Fifty-four consecutive patients with HSCC cupulolithiasis were included, and immediate treatment efficacy of CuRM and short-term treatment efficacy of FPP were investigated.

RESULTS

We performed the CuRM in HSCC cupulolithiasis, and, if the CuRM did not show immediate success, instructed the patients to perform the FPP or the sham position (by random allocation) at home. The immediate therapeutic success of the CuRM was assessed by the absence of nystagmus and vertigo on positional testing after 30 minutes of the maneuver, which was 14.8% on the first visit day. And the resolution rate of HSCC cupulolithiasis was higher in the FPP group than in the sham position group at the second (78.3% vs 55.6%), third (75.0% vs 42.9%), and fourth visits (100% vs 25.0%).

CONCLUSION

Although the CuRM has been considered to be a good therapeutic option for HSCC cupulolithiasis because it theoretically aims to detach otoconial particles attached both on the utricle and canal sides of the cupula, the immediate success rate was only 14.8% at the first visit. The FPP can be additionally recommended to improve the resolution rate in HSCC cupulolithiasis patients in whom the CuRM fails.

New Therapeutic Maneuver for Horizontal Semicircular Canal Cupulolithiasis: A Prospective Randomized Trial

Background: There are debates on whether mastoid oscillation has any benefit or harm in treating horizontal semicircular canal (HSCC) cupulolithiasis. The goal of this study was to investigate the therapeutic effects of the new maneuver using only inertia and gravity and compare it with the previously reported cupulolith repositioning maneuver using mastoid vibration (CuRM). Methods: We enrolled 57 patients diagnosed with HSCC cupulolithiasis. Patients were randomly allocated to the previously reported CuRM or the new maneuver (briefly, 30° head rotation to the affected side and thereafter bidirectional side-lying) using simply inertia and gravity, and their immediate and short-term effects were evaluated. Results: The immediate success rate did not differ significantly between the CuRM (8 of 22, 36.4%) and the new maneuver (10 of 35, 28.6%) groups (p = 0.538, Pearson’s chi-square test). The late resolution rates at the first follow-up of the CuRM (75%, 9 of 12) and new maneuver groups (82.6%, 19 of 23) were very high, and there was no statistical difference between them (p = 0.670, Fisher’s exact test). Conclusions: This study showed that the new maneuver was effective for treating HSCC cupulolithiasis with an immediate success rate of 28.6% (10 of 35). Although it did not show better results than the existing maneuver using vibration, there was no statistical difference. Considering the debate on the effectiveness of oscillation, we believe our new maneuver is a conservative alternative that uses only inertia and gravity, and it can be easily performed in clinics where oscillation equipment is not available.

Apogeotropic Horizontal Canal Benign Paroxysmal Positional Vertigo: Zuma e Maia Maneuver versus Appiani Variant of Gufoni

Benign paroxysmal positional vertigo (BPPV) is one of the most common disorders that causes dizziness. The incidence of horizontal semicircular canal (HSC) BPPV ranges from 5% to 40.5% of the total number of BPPV cases diagnosed. Several studies have focused on establishing methods to treat BPPV caused by the apogeotropic variant of the HSC, namely, the Appiani maneuver (App). In 2016, a new maneuver was proposed: the Zuma e Maia maneuver (ZeM), based on inertia and gravity. The aim of this study is to analyze the efficacy of App versus ZeM in the resolution of episodes of BPPV produced by an affectation of the horizontal semicircular canal with apogeotropic nystagmus (Apo-HSC). A retrospective, quasi-experimental study was conducted. Patients attended in office (November 2014–February 2019) at a third-level hospital and underwent a vestibular otoneurology assessment. Those who were diagnosed with Apo-HSC, treated with App or ZeM, were included. To consider the efficacy of the maneuvers, the presence of symptoms and/or nystagmus at the first follow up was studied. Patients classified as “A” were those with no symptoms, no nystagmus; “A/N+”: no symptoms, nystagmus present during supine roll test; “S”: symptoms present. Previous history of BPPV and/or otic pathology and calcium levels were also compiled. From the 54 patients included, 74% were women. The average age was 69. Mean follow-up: 52.51 days. In those patients without previous history of BPPV (n = 35), the probability of being group “A” was 63% and 56% (p = 0.687) when treated with App and ZeM, respectively, while being “A/N+” was 79% and 87% for App and ZeM (p = 0.508). Of the 19 patients who had previous history of BPPV, 13% and 64% were group “A” when treated with App and ZeM (p = 0.043), and 25% and 82% were “A/N+” after App and ZeM, respectively (p = 0.021). In conclusion, for HSC cupulolithiasis, ZeM is more effective than App in those cases in which there is a history of previous episodes of BPPV (“A”: 64% (p = 0.043); “A/N+”: 82% (p = 0.021)).

[Significance of rapid axial roll test in determining the responsible semicircular canal for horizontal canal benign paroxysmal positional vertigo]

Objective:To compare the diagnostic performance of the rapid axial roll test（RART） and the traditional roll test（SRT）in determining the responsible semicircular canal for horizontal canal benign paroxysmal positional vertigo（HC-BPPV）. Methods:A total of 400 patients diagnosed with HC-BPPV from January 2020 to December 2020 were collected and randomly divided into two groups. Among them, there were 202 cases in the RART group and 198 cases in the SRT group. The patients in the two groups performed corresponding positional test respectively, and the following treatment was based on the types of induced nystagmus. The patients with typical HC-BPPV nystagmus underwent two rounds of modified Barbecure procedure. The diagnostic accuracies of the two positional tests in locating the responsible semicircular canal were evaluated by the elicitation rate of typical nystagmus. Finally, the effects of the two tests were evaluated by comparing the recovery rate of nystagmus between the two groups after repositioning procedures. Results:The elicitation rate of nystagmus in HC-BPPV patients by RART was significantly higher than that by SRT（χ²=10.73，P<0.01 ）. The effectiveness of repositioning procedure by RART in HC-BPPV patients was significantly higher than that of SRT（χ²=6.08，P<0.05）. Conclusion:RART could significantly improve the accuracy in determining the responsible semicircular canal in HC-BPPV, and future studies are warranted.

Immediate and short-term effects of Gufoni and Appiani liberatory maneuver for treatment of ageotropic horizontal canal benign paroxysmal positional vertigo: A prospective randomized trial

OBJECTIVE

To examine the treatment effects of repositioning maneuvers with the head turned 45° downwards (Gufoni maneuver) and 45° upwards (Appiani maneuver) in 25 patients with ageotropic horizontal semicircular canal (HSCC) benign paroxysmal positional vertigo (BPPV).

METHODS

Patients were randomly assigned to the Gufoni or Appiani maneuvers, and their immediate and short-term efficacy was investigated.

RESULTS

The immediate treatment response was successful in four of 16 patients who were treated with the Appiani maneuver and were not successful in any of the nine patients treated with the Gufoni maneuver. The patients who showed spontaneous resolution during follow-up outnumbered the patients who showed resolution of ageotropic HSCC BPPV immediately after the repositioning maneuvers.

CONCLUSION

This study showed a very low immediate resolution rate of ageotropic HSCC BPPV after the Gufoni maneuver; this may be attributed to the less effectiveness of the Gufoni maneuver against debris that often exists in the canal side of the cupula. Another interesting finding was that the rate of spontaneous resolution during the follow-up period was higher than that of immediate resolution after the repositioning maneuvers, which may support the recently proposed hypothesis that ageotropic positional nystagmus can also be evoked by causes other than the otolithic attachment on the cupula, such as a slight change in the biochemical composition of the inner ear fluids.

LEVEL OF EVIDENCE

3.

Square wave manoeuvre for apogeotropic variant of horizontal canal benign paroxysmal positional vertigo in neck restricted patients

Objective

We aimed to describe the clinical features of the apogeotropic variant of horizontal canal benign paroxysmal positional vertigo (HC BPPV-AG) in a cluster of patients with restrictive neck movement disorders and a new therapeutic manoeuvre for its management.

Methods

In a retrospective review of cases from an ambulatory tertiary referral center, patients with HC BPPV-AG in combination with neck movement restriction that prevented any classical manual repositioning procedure or who were refractory to canalith repositioning manoeuvres, were treated with a new manoeuvre comprised of sequential square-wave pattern of head and body supine rotations while nystagmus was being monitored, until either an apogeotropic to geotropic conversion or resolution of the nystagmus was observed.

Results

Fifteen patients were studied. All but one [14/15 cases] showed a positive therapeutic response to the repositioning procedure in a single session. In two cases, a direct relief of vertigo and elimination of nystagmus was observed without an intermediate geotropic phase. Although in three patients the affected ear was not initially identified, it was ultimately identified and successfully treated by the square wave manoeuvre in all of them.

Conclusions

The square-wave manoeuvre is an alternative for HC BPPV-AG treatment in either cases with neck restriction, where the affected side is not well identified at the bedside or when other manoeuvres fail to resolve the HC BPPV-AG.

Upright BPPV Protocol: Feasibility of a New Diagnostic Paradigm for Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo Compared to Standard Diagnostic Maneuvers

Background: The diagnosis of benign paroxysmal positional vertigo (BPPV) involving the lateral semicircular canal (LSC) is traditionally entrusted to the supine head roll test, also known as supine head yaw test (SHYT), which usually allows identification of the pathologic side and BPPV form (geotropic vs. apogeotropic). Nevertheless, SHYT may not always allow easy detection of the affected canal, resulting in similar responses on both sides and intense autonomic symptoms in patients with recent onset of vertigo. The newly introduced upright head roll test (UHRT) represents a diagnostic maneuver for LSC-BPPV, supplementing the already-known head pitch test (HPT) in the sitting position. The combination of these two tests should enable clinicians to determine the precise location of debris within LSC, avoiding disturbing symptoms related to supine positionings. Therefore, we proposed the upright BPPV protocol (UBP), a test battery exclusively performed in the upright position, including the evaluation of pseudo-spontaneous nystagmus (PSN), HPT and UHRT. The purpose of this multicenter study is to determine the feasibility of UBP in the diagnosis of LSC-BPPV.

Methods: We retrospectively reviewed the clinical data of 134 consecutive patients diagnosed with LSC-BPPV. All of them received both UBP and the complete diagnostic protocol (CDP), including the evaluation of PSN and data resulting from HPT, UHRT, seated-supine positioning test (SSPT), and SHYT.

Results: A correct diagnosis for LSC-BPPV was achieved in 95.5% of cases using exclusively the UBP, with a highly significant concordance with the CDP (p < 0.000, Cohen's kappa = 0.94), regardless of the time elapsed from symptom onset to diagnosis. The concordance between UBP and CDP was not impaired even when cases in which HPT and/or UHRT provided incomplete results were included (p < 0.000). Correct diagnosis using the supine diagnostic protocol (SDP, including SSPT + SHYT) or the sole SHYT was achieved in 85.1% of cases, with similar statistical concordance (p < 0.000) and weaker strength of relationship (Cohen's kappa = 0.80).

Conclusion: UBP allows correct diagnosis in LSC-BPPV from the sitting position in most cases, sparing the patient supine positionings and related symptoms. UBP could also allow clinicians to proceed directly with repositioning maneuvers from the upright position.

Management of Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vestibular vertigo. It is caused by free-floating otoconia moving freely in one of the semicircular canals (canalolithiasis) or by otoliths adhered to the cupula (cupulolithiasis). The posterior canal is the most common canal affected, followed by the lateral canal. Diagnosis of the side affected is critical for successful treatment; therefore, suppressing visual fixation is essential to examination of these patients' eye movement. On the basis of our experience, we have adopted the Zuma maneuver and the modified Zuma maneuver for both apogeotropic and geotropic variants of lateral canal BPPV. Knowledge of the anatomy and pathophysiologic mechanisms of the semicircular canals is essential for correct management of these patients. Hence, using a single maneuver and its modification may facilitate daily neurotological practice.

Upright head roll test: A new contribution for the diagnosis of lateral semicircular canal benign paroxysmal positional vertigo

Diagnosing the affected side in Benign Paroxysmal Positional Vertigo (BPPV) involving the Lateral Semicircular Canal (LSC) is often challenging and uncomfortable in patients with recent onset of vertigo and intense autonomic symptoms. The Minimum Stimulus Strategy (MSS) aims to diagnose side and canal involved by BPPV causing as little discomfort as possible to the patient. The strategy applied for LSC-BPPV includes the evaluation of pseudo-spontaneous nystagmus and oculomotor responses to the Head Pitch Test (HPT) in upright position, to the seated-supine test and to the Head Yaw Test (HYT) while supine. Matching data obtained by these tests enables clinicians to diagnose the affected side in LSC-BPPV. The purpose of this preliminary study is to propose a new diagnostic test for LSC-BPPV complimentary to the HPT, the Upright Head Roll Test (UHRT), to easily determine the affected ear and the involved arm in the sitting position and to evaluate its efficiency. Our results suggest that the UHRT can increase the sensitivity of the MSS without resorting to the HYT, thus reducing patient's discomfort.

Double-blind randomized controlled trial on efficacy of cupulolith repositioning maneuver for treatment of apogeotropic horizontal canal benign paroxysmal positional vertigo

Backgrounds: Although various therapeutic maneuvers have been proposed, it is still unclear which maneuver is better to treat apogeotropic horizontal canal benign paroxysmal positional vertigo (HC-BPPV).Objectives: This study aimed to assess the therapeutic efficacy of the cupulolith repositioning maneuver (CuRM) in apogeotropic HC-BPPV in comparison with the therapeutic head-shaking maneuver and modified Lempert maneuver.Materials and Method: This is double-blind randomized prospective study. Forty-nine consecutive patients diagnosed with apogeotropic HC-BPPV were allocated randomly to CuRM (n = 18), therapeutic head-shaking (n = 16), or modified Lempert maneuver (n = 15). The presence of nystagmus and vertigo on positional testing were evaluated at 30 min, on 1 day, and 1 week after treatment.Results: There were no significant differences in any clinical characteristics between the three groups at randomization. After a single trial of therapeutic maneuvers on the initial visit day, the CuRM (38.9%) and therapeutic head shaking maneuver (12.5%) did not show differences compared to modified Lempert maneuver (33.3%). The therapeutic effects on the 2nd day and at 1 week after treatment also did not differ between the three groups.Conclusions: Although the CuRM is theoretically considered to be a better therapeutic method, the therapeutic efficacy of CuRM was not statistically different compared to the other two maneuvers.

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.

The effective clinical outcomes of the Gufoni maneuver used to treat 91 vertigo patients with apogeotropic direction-changing positional nystagmus (apo-DCPN)

This study aimed to observe and analyze the effects and outcomes of patients with apogeotropic direction-changing positional nystagmus (apo-DCPN) who received Gufoni maneuver.A total of 91 patients with positional vertigo admitted to the specialized dizziness clinic in Zhejiang Provincial People's Hospital from February 2014 to August 2017 were included. The immediate treatment responses to the Gufoni maneuver were observed and recorded. The patients in whom the treatment was ineffective were followed up for 4 weeks to observe the outcome of apo-DCPN.In 21 patients, the apo-DCPN was transformed after Gufoni maneuver, and 7 patients developed transformation within 4 weeks of follow-up. Spontaneous remission of apo-DCPN within the follow-up period was observed in 55 patients who were unresponsive to the Gufoni maneuver. The prevalence of migraine was significantly higher in the early remission group (P < .05) and the period between the initial visit and nystagmus remission was significantly shorter in the group of patients with migraine history (P < .05).This study demonstrates that the immediate treatment efficacy of the Gufoni maneuver is poor in positional vertigo patients with apo-DCPN. We believe that the reason for the low efficacy is that the Gufoni maneuver is only effective for some patients with apo-DCPN type HSC-BPPV. In patients with early spontaneous remission and a history of migraine, central positional nystagmus of probable vestibular migraine (VM) or benign recurrent vertigo should be considered for the mechanisms of apo-DCPN generation.

In whom does horizontal canal BPPV recur?

PURPOSE

The objective of this study is to examine the rate of horizontal canal BPPV recurrence of the same type and search for predisposing factors.

Treatment of benign paroxysmal positional vertigo. A clinical review

Benign paroxysmal positional vertigo (BPPV) is the most frequent episodic vestibular disorder. It is due to otolith rests that are free into the canals or attached to the cupulas. Well over 90% of patients can be successfully treated with manoeuvres that move the particles back to the utriculus. Among the great variety of procedures that have been described, the manoeuvres that are supported by evidenced-based studies or extensive series are commented in this review. Some topics regarding BPPV treatment, such as controlling the accuracy of the procedures or the utility of post-manoeuvre restrictions are also discussed.

Advances in the diagnosis and treatment of benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) (otolith disease) is the most common neurological and position change related vertigo, accounting for 17-20% of peripheral vertigo. BPPV occur in the elderly. The high incidence age for BPPC was 50 to 70 years and mostly in female. According to the different parts of the lesions, it is divided into anterior canal BPPV (AC-BPPV), posterior canal BPPV (PC-BPPV), horizontal canal BPPV (HC-BPPV). Studies have shown that the incidence of PC-BPPV was 86.36%, the incidence of HC-BPPV was 11.37%, the incidence rate of AC-BPPV was 2.27%. Treatment for PC-BPPV includes manual reduction, drug treatment, psychological treatment, and surgical treatment. Repositioning is the preferred method for the treatment of PC-BPPV with high effective rate and low risk. The mechanism is through the different changes of head position to make the otolith back to utricle. Many manual reduction methods have been reported in clinical treatment of PC-BPPV. With the increasing emphasis on the BPPV, a variety of new methods are being developed and designed.

Practice Guidelines for the Diagnosis and Management of Benign Paroxysmal Positional Vertigo Otoneurology Committee of Spanish Otorhinolaryngology and Head and Neck Surgery Consensus Document

Benign Paroxysmal Positional Vertigo is the most frequent episodic vestibular disorder. The purpose of this guide, requested by the committee on otoneurology of the Spanish Society of Otolaryngology and Head and Neck Surgery, is to supply a consensus document providing practical guidance for the management of BPPV. It is based on the Barany Society criteria for the diagnosis of BPPV. This guideline provides recommendations on each variant of BPPV, with a description of the different diagnostic tests and the therapeutic manoeuvres. For this purpose, we have selected the tests and manoeuvres supported by evidence-based studies or extensive series. Finally, we have also included a chapter on differential diagnosis and a section relating to general aspects in the management of BPPV.

New Treatment Strategy for Apogeotropic Horizontal Canal Benign Paroxysmal Positional Vertigo

The apogeotropic variant of horizontal semicircular canal benign paroxysmal positional vertigo (HC-BPPV) is attributed to canalithiasis of the anterior arm or cupulolithiasis. Despite some therapeutic maneuvers, I propose a new treatment strategy for apogeotropic HC-BPPV that is designed to detach both the otoconial debris from the anterior arm of the semicircular canal and the debris that is attached to the utricular side of the cupula using inertia and gravity and based on simulations with a 3D biomechanical model.

Change of nystagmus direction during a head-roll test in lateral semicircular canal cupulolithiasis

OBJECTIVE

To demonstrate positional nystagmus during a head-roll test in two patients with lateral semicircular canal (LSCC) cupulolithiasis who presented with spontaneous detachment of otoliths from the LSCC cupula, and to confirm that otoliths may adhere to both the utricle and canal sides of the cupula.

PATIENTS AND METHODS

Using video nystagmography, positional nystagmus was evaluated in two patients with LSCC cupulolithiasis who showed the change of nystagmus direction during a head-roll test.

RESULTS

Both patients presented with persistent left-beating and right-beating nystagmus when the head was bent forward and backward, respectively. This suggests the presence of either cupulolithiasis on the right side or light cupula on the left side of the LSCC. In Case 1, transformation from cupulolithiasis to canalolithiasis occurred, implicating the detachment of otoliths from the canal side of the right LSCC cupula. In Case 2, vigorous right-beating nystagmus was followed by persistent left-beating nystagmus when the head was rolled to the left. Following this, direction-fixed left-beating nystagmus was observed at all positions, which may indicate that otoliths attached on utricle side of the right LSCC cupula were detached and fell into the utricle under the influence of gravity. A conversion of nystagmus direction may be explained by an expression of short-term adaptation of vestibular tone.

CONCLUSIONS

Otoliths can be attached to either side of the cupula in LSCC cupulolithiasis. Because it is difficult to determine the attached side at the time of diagnostic maneuver, the therapeutic approach should include maneuvers designed to detach otolith particles from both the utricle and canal side.