Impaired Calcium Metabolism in Benign Paroxysmal Positional Vertigo: A Topical Review

Objective findings in patients with multi-canal benign paroxysmal positional vertigo

OBJECTIVE

The study aimed to investigate the clinical characteristics of patients with multi-canal benign paroxysmal positional vertigo (MC-BPPV).

METHODS

We performed a retrospective analysis of 927 patients with BPPV who were admitted to our hospital between January 1, 2016 and December 31, 2019. The clinical data of all patients were collected. The Dix-Hallpike, straight head-hanging, and supine Roll tests were performed in all patients. The nystagmus was recorded using videonystagmography. The clinical characteristics of patients with MC-BPPV and single canal BPPV (SC-BPPV) was analyzed and compared.

RESULTS

Among 927 patients included, 49 (5.29%) patients had MC-BPPV, 878 (94.71%) patients had SC-BPPV. There were significant differences in the male to female ratio (1:3.90 vs 1:1.81, P < .05), mean age (62.47±12.51 vs 59.04±13.72, P < .05), as well as the ratio of cupulolithiasis to canalithiasis (1:1.45 vs 1:4.78, P < .01) between patients with MC-BPPV and SC-BPPV. The frequency of involvement of PC, HC, and AC were involved for 66 (67.35%), 23 (23.47%), and 9 (9.18%) times, respectively, in patients with MC-BPPV, which were involved in 581 (66.17%), 281 (32.0%), and 16 (1.82%) patients, respectively, in patients with SC-BPPV. No significant difference was found in the frequency of involvement of PC and HC between patients with MC-BPPV and SC-BPPV, while there was significant difference in the frequency of AC involvement between 2 groups (P < .01). Ipsilateral PC-HC-BPPV (n = 18) and bilateral PC-BPPV (n=19) were the most common among patients with MC-BPPV. Twenty-six (53.06%) patients had ipsilateral MC-BPPV, 23 (46.94%) had bilateral MC-BPPV. Of the 26 patients with ipsilateral MC-BPPV, 7 patients combined with unilateral peripheral vestibular disorder.

CONCLUSION

Patients with MC-BPPV had a significantly older mean age at disease onset and a higher proportion of females compared with patients with SC-BPPV. Cupulolithiasis was more common in MC-BPPV. AC involvement was also much more common in MC-BPPV than in SC-BPPV.

Assessment of vitamin D deficiency in recurrent BPPV patients: A cross-sectional study

PURPOSE

This study aimed to investigate the vitamin D deficiency of patients with BPPV recurrence and to evaluate the differences of 25-hydroxy vitamin D (25(OH)D) and serum calcium levels among gender and age categories.

METHODS

This cross-sectional study enrolled patients with BPPV. The diagnosis of BPPV was based on positional nystagmus and vertigo induced by certain head positions (The Dix-Hallpike maneuver and head roll tests). All patients' age, serum 25(OH)D, calcium measurements and recurrence data were collected and analyzed.

RESULTS

The median of 25(OH)D was 15.32 (IQR 10.61, 20.90) ng/ml. The recurrent group showed lower 25(OH)D levels than that of non-recurrent group [13.28 (IQR 9.47, 17.57) ng/ml vs 16.21 (IQR 11.49, 21.13) ng/ml]. There were significant differences of 25(OH)D levels among age categories. The proportion of vitamin D deficiency in patients ≥60 years old was lower than that in the other two groups.

CONCLUSION

Our study suggested that BPPV patients had a decreased 25(OH)D level and a high incidence of vitamin D deficiency. The 25(OH)D level of recurrent BPPV patients was lower than that in non-recurrent ones. Among them, the elderly group (≥60 years) took the preponderance, which had the lowest incidence of vitamin D deficiency and the highest incidence of vitamin D sufficiency.

A Rare Presentation of Multicanal Benign Paroxysmal Positional Vertigo in a Premenopausal Woman With Osteopenia: A Case Report

We report a case of non-traumatic, multicanal benign paroxysmal positional vertigo (BPPV) in a premenopausal, osteopenic 35-year-old female with corresponding low bone mineral density. Dix-Hallpike and supine roll tests confirmed unilateral posterior canal (PC) BPPV from 2012-2014, and later, a rare presentation of multicanal BPPV with specifically ipsilateral horizontal canals (HC) and anterior canals (AC) affected in 2015. Heel scans displayed T-scores within the osteopenia range in 2012 until levels normalized one year later. Despite treatment with indicated canalith repositioning treatments (CRTs), symptoms continued to persist. Complete resolution of symptoms occurred in 2016, which is most likely due to self-treatment with daily 5000 IU vitamin D in 2015. This case emphasizes the rare presentation of unilateral single-canal BPPV to multi-canal BPPV, along with the importance of vitamin D treatment in preventing the recurrence of symptoms.

Gene expression analysis in recurrent benign paroxysmal positional vertigo: a preliminary study

Objectives

This study aimed to determine the pathophysiology of recurrent benign paroxysmal positional vertigo (BPPV) in young patients using gene expression profiling combined with bioinformatics analysis.

Methods

Total RNA was extracted from the whole blood of four young patients with recurrent BPPV and four controls. The differentially expressed genes (DEGs) between the groups were screened using a microarray analysis based on the cutoff criteria of |log₂ fold change| > 1 and an adjusted p-value of < 0.05. Functional enrichment analysis of DEGs was performed using Gene Ontology analysis, and the protein-protein interaction (PPI) network was constructed using the Search Tool for the Retrieval of the Interacting Genes database.

Results

A total of 39 DEGs were detected between the BPPV and control samples, comprising 33 upregulated DEGs and six downregulated DEGs in the BPPV group. Functional enrichment analysis indicated that the upregulated DEGs were significantly enriched in terms related to metabolic processes and the immune system. Two main pathways were extracted from the PPI network: one was associated with oxidative phosphorylation and stress and the other with the adaptive immune system and extracellular matrix degradation.

Conclusion

The findings of our bioinformatics analysis indicated that oxidative stress or extracellular matrix degradation due to immune-mediated inflammatory responses may contribute to the development of recurrent BPPV in young patients.

Assessment of Osteoporosis and Vitamin D3 Deficiency in Patients with Idiopathic Benign Paroxysmal Positional Vertigo (BPPV)

Background and objectives: Osteoporosis and vitamin D3 deficiency may be risk factors of benign paroxysmal positional vertigo (BPPV). The aim of this study was to assess the prevalence of osteoporosis and 25(OH) vitamin D3 deficiency in a group of patients with idiopathic benign paroxysmal positional vertigo. Materials and Methods: Thirty-five patients (twenty-eight women and seven men) with posterior semicircular canal BPPV were enrolled in the study. The subjects underwent hearing assessment (tonal audiometry and impedance audiometry) and the Dix-Hallpike maneuver. Serum 25(OH) vitamin D3 levels were determined and lumbar spine bone densitometry was performed. The relationships between sex, age, height, Body Mass Index (BMI), vitamin D3 levels and bone densitometry results were assessed. Results: The diagnosis of osteoporosis was confirmed in 1 patient (3%), 3 subjects were osteopenic (8.6%), and normal bone densitometry was found in 31 (88.6%) patients. Conclusions: We found no statistically significant relationships between age, BMI or vitamin D3 levels and bone densitometry results in patients with idiopathic BPPV.

Investigation of serum calcium and vitamin D levels in superior semicircular canal dehiscence syndrome: A case control study

Objective

It remains unknown whether calcium metabolism has any effect on the clinical presentation of superior semicircular canal dehiscence (SSCD). Our aim was to analyse the adjusted calcium and vitamin D levels in SSCD patients compared to a control group.

Methods

This was a prospective case-control study performed in a tertiary referral center, university teaching hospital in the UK. It included all new patients with SSCD seen in a dedicated skull base clinic over a 5-year period (2015-2019) compared to a gender and age matched control group. The main outcome of the study was adjusted calcium and Vitamin D levels between the two groups.

Results

A total of 31 SSCD patients were recruited with a matched number of control patients. The mean Vitamin D level on the SSCD group was 44.8 nmoL/l (SD: 20.8) compared to 47.5 nmoL/l (SD: 27.4) on the control group (p = 0.702). Mean Adjusted calcium level was 2.34 mmoL/l (SD: 0.7) for SSCD compared to 2.41 mmoL/l (SD: 0.11) for controls (p = 0.01), being within normal limits for both the SSCD and the control group.

Conclusion

Our study did not identify a link between Vitamin D levels and presence of SSCD. Normal adjusted calcium values were found in both groups. Despite that a statistically significant lower calcium level was found in the SSCD group which could indicate that suboptimal levels of calcium may affect the micro-environment of the otic capsule at the SSC region.

Predictors for hospital admission in emergency department patients with benign paroxysmal positional vertigo: A retrospective review

OBJECTIVE

This study aims to assess the incidence of Emergency Department (ED) visits for benign paroxysmal positional vertigo (BPPV), describe patient characteristics, management practices and predictors of inpatient admission of BPPV patients.

METHODS

This was a retrospective chart review of patients presenting with BPPV to a single ED between November 2018 and August 2020. Patients' characteristics, ED management, discharge medications, disposition and unscheduled return visits were determined.

RESULTS

In total, 557 patients were included. Average age was 49 years, 54.2% were females and 12.4% required hospital admission. In the ED, 51.1% received intravenous hydration, 33.8% received anti-emetics, 10.1% received benzodiazepines, 31.8% underwent canalith repositioning maneuvers (CRMs) and 56.7% were discharged on acetyl-leucine. Of discharged patients, 2.5% had unscheduled return visits. A higher likelihood of admission was associated with age above 54 years (aOR = 4.86, p<0.001, 95% CI [2.67, 8.86]), home use of proton pump inhibitors (PPIs) (aOR = 2.44, p = 0.03, 95% CI [1.08, 5.53]), use of anti-emetics and benzodiazepines in the ED (aOR = 2.34, p = 0.003, 95% CI [1.34, 4.07]) and (aOR = 2.18, p = 0.04, 95% CI [1.03, 4.64]), respectively.

CONCLUSION

While BPPV is a benign diagnosis, a significant number of patients presenting to the ED require admission. Predictors of admission include older age, PPIs use and ED treatment with anti-emetics and benzodiazepines. Although CRMs are the gold standard for management, CRMs usage did not emerge as protective from admission, and our overall usage was low.

Vitamin D Supplementation for Benign Paroxysmal Positional Vertigo: A Systematic Review

OBJECTIVE

Benign paroxysmal positional vertigo (BPPV) is commonly attributed to displaced otoconia. These have been shown to have biomineralization close to that of bone, and vitamin D deficiency has been associated with BPPV. We aim to systematically review the available literature on vitamin D supplementation and BPPV intensity and recurrence in adults.

DATABASES REVIEWED

PubMed, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Current Controlled Trials, and ClinicalTrials.gov.

METHODS

We systematically reviewed the available literature from 1947 to April 2020. The study protocol was registered in the PROSPERO database (trial registration: CRD42020183195).

RESULTS

A total of 179 abstracts were identified and screened by two independent reviewers. Based on inclusion and exclusion criteria, six studies were selected and subjected to a quality assessment. In one randomized clinical trial (RCT), vitamin D supplementation was found to reduce annual recurrence rate of vertigo in patient with BPPV and subnormal serum vitamin D levels compared with placebo (odds ratio, 0.69; 95% confidence interval, 0.54-0.90). Non-RCTs demonstrated the possibility of a null effect in the random effects model (odds ratio, 0.08; 95% confidence interval, 0.00-1.56). The RCT considered as low risk of bias. All of the nonrandomized studies were assessed as serious risk of bias.

CONCLUSIONS

The intervention studies identified consistently demonstrated a decrease in BPPV recurrence with supplementation of vitamin D in patients with subnormal vitamin D levels. Although there is a paucity of high-quality studies, the present literature does highlight a role for optimization of vitamin D levels in patients with BPPV.

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 &lt; 0.001). The slow phase velocity (SPV) of induced nystagmus at half D-HT supine position was slower than D-HT supine position (P &lt; 0.05) and SHH supine position (P &lt; 0.05). The nystagmus latency of D-HT supine position was significantly shorter than half D-HT (P &lt; 0.05) and SHH (P &lt; 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.

Serum 25-Hidroksi D Vitamini ve Kalsiyum Seviyeleri ile İdiyopatik Benign Paroksismal Pozisyonel Vertigo Arasındaki İlişki

Amaç: Kliniğimize baş dönmesi şikâyeti ile başvurup idiopathic benign paroksismal pozisyonel vertigo (BPPV) tanısı alan hastalar ile baş dönmesi olmayan sağlıklı kontrol grubunun 25-hidroksi vitamin D (25-OH vitamin D) ve Ca2+ düzeylerinin karşılaştırılması Ca2+ ve 25-OH vitamin D’nin BPPV gelişimindeki rolünün araştırılmasıdır. Gereç ve Yöntem: Çalışmamız geriye dönük vaka kontrol çalışması olup, 01.01.2018-01.08.2021 arası Alanya Egitim ve Araştırma Hastanesi Nöroloji polikliniğine başvuran İdiopatik BPPV tanısı alan 409 hasta ile kontrol grubu olarak kliniğimize başvuru öncesi son 1 yıl içerisinde vertigo, dizziness ya da dengesizlik nedeniyle hekim başvurusu olmayan serum D vitamini düzeyi ölçümü yapılmış 338 hasta seçilerek oluşturuldu. İstatiksel değerlendirmeler için ki-kare ve T testi testi kullanıldı. Bulgular: Ortalama serum 25-OH vitamin D düzeyleri BPPV ve kontrol grubunda sırasıyla 15,74 ng/mL ve 17,91 ng/mL idi. Serum 25-OH vitamin D düzeyleri BPPV grubunda kontrol grubuna göre anlamlı derecede düşük bulundu ((p=0,01, p

Relationship between osteoporosis and benign paroxysmal positional vertigo based on evidence-based medicine and bioinformatics

It has been reported that osteoporosis is a possible risk factor of benign paroxysmal positional vertigo (BPPV).

PURPOSE

We analyzed the correlation between osteoporosis and BPPV and the possible mechanism by performing evidence-based medicine meta-analysis and bioinformatics analysis.

METHODS

Initially, English articles related to osteoporosis and BPPV were obtained through PubMed and EMBASE databases. Stata12.0 software was used for meta-analysis to calculate the odd ratio (OR) and 95% confidence interval (CI) of outcome indicators, and the heterogeneity was evaluated by subgroup analysis, publication bias evaluation, and sensitivity analysis. In addition, microarray datasets related to BPPV and osteoporosis were obtained from gene expression omnibus (GEO) database to screen differentially expressed genes. At last, a mouse model of osteoporosis was established by bilateral oophorectomy for validation. RT-qPCR and Western blot analysis were performed to determine expression of related factors in mouse tissues.

RESULTS

Osteoporosis was suggested as an important risk factor for BPPV through meta-analysis of these 12 articles. It was found that PPP2CA was upregulated in BPPV and low bone mineral density (BMD) samples. Moreover, PPP2CA induced dephosphorylation of BCL2, which may be involved in BPPV through regulation of BMD. Through this mechanism, silencing of PPP2CA could elevate the incidence of BPPV by promoting bone remodeling and reducing the density of otoconia around the macula.

CONCLUSIONS

PPP2CA reduces BMD expression by inducing dephosphorylation of BCL2, which may be one of the mechanisms responsible for the onset of BPPV in osteoporosis.

Characteristics of bone metabolism in postmenopausal female patients with different types of idiopathic benign paroxysmal positional vertigo: A single-centre retrospective study

OBJECTIVE

The association between benign paroxysmal positional vertigo (BPPV) and impaired calcium metabolism has attracted widespread interest. Several studies have suggested that decreased bone mineral density (BMD) and serum 25-hydroxyvitamin D (25(OH)D) level are related to the occurrence and/or recurrence of BPPV; however, the characteristics of bone metabolism in patients with BPPV subtypes have not been fully investigated, and conclusions have been controversial. This study aimed to evaluate BMD and serum levels of 25(OH)D and bone turnover markers to clarify the characteristics of bone metabolism in patients with different types of BPPV.

METHOD

We retrospectively analysed the data of new-onset idiopathic postmenopausal female patients with BPPV at our institution from January 2016 to January 2020. The patients' demographic data including age, medication history, concomitant diseases, onset time, clinical form, laboratory indicators, such as serum levels of 25(OH)D, bone formation markers, namely, amino-terminal propeptide of type I procollagen (PINP) and osteocalcin (OC), bone resorption marker, namely, β-isomerized carboxy-terminal telopeptide of type I collagen (β-CTX), and BMD were collected and analysed.

RESULTS

This study included 201 consecutive postmenopausal female patients with BPPV. Among them, 138 were diagnosed with posterior semicircular canal BPPV, 42 were diagnosed with lateral semicircular canal canalolithiasis, and 21 were diagnosed with lateral semicircular canal cupulolithiasis. There were no significant differences in age distribution, body mass index, clinical history, levels of albumin, globulin, uric acid, creatinine, or blood urea nitrogen, lipid profiles (except high-density lipoprotein cholesterol) and routine blood parameters among these groups (P > 0.05). There were no significant differences in the mean T-score and BMD values of different sites or in the serum levels of 25(OH)D and bone turnover markers (PINP, OC and β-CTX) among the subgroups (P > 0.05). The proportion of reduction in BMD (T-score < -1 SD) and decreased serum vitamin D level (< 20 ng/ml) were not significantly different between the subgroups (P > 0.05).

CONCLUSION

There were no significant differences in bone metabolism in postmenopausal female patients with different types of idiopathic BPPV.

No evidence for a specific vitamin D deficit in benign paroxysmal positional vertigo

BACKGROUND AND PURPOSE

The aim was to investigate whether there is a difference in serum 25-hydroxyvitamin D (25(OH)D) concentration between patients with benign paroxysmal positional vertigo (BPPV), patients with other vestibular diseases and patients with other neurological non-vestibular diseases presenting in a tertiary neurological academic outpatient clinic.

METHODS

The serum 25(OH)D concentration was measured in 680 patients (368 male, mean age ± SD 58 ± 17 years, 661 Caucasian) without vitamin D supplementation. 158 patients had BPPV; 221 had other vestibular diseases (including 122 with peripheral vestibular disorders, such as unilateral vestibulopathy or Ménière's disease; 46 with central vestibular disorders, such as vestibular migraine or cerebellar dizziness; 53 with functional dizziness); and 301 patients with other neurological non-vestibular diseases.

RESULTS

There was no significant difference in the serum 25(OH)D concentration between patients with BPPV (mean ± SD 23.4 ± 9.4 ng/ml) and those with other vestibular disorders (24.9 ± 10.1 ng/ml, p = 0.324). Patients with other neurological disorders had even lower concentrations (21.4 ± 10.6 ng/ml) than patients with BPPV (p < 0.005), patients with other vestibular disorders (p < 0.005) and all patients with vestibular disorders (24.9 ± 10.1 ng/ml, p < 0.005).

CONCLUSION

Our analysis does not support the theory of a specific relationship between serum 25(OH)D concentration and the occurrence of BPPV or other vestibular disorders.

Investigation of Serum Calcium and 25-Hydroxy Vitamin D Levels in Benign Paroxysmal Positional Vertigo Patients

OBJECTIVE

Benign paroxysmal positional vertigo (BPPV) is characterized by recurrent attacks of vertigo caused by head movements. It occurs as a result of otoconia falling into the semicircular canal. Calcium and 25 hydroxyvitamin D [25(OH)D] metabolism in the inner ear play an important role in otoconia formation and degeneration. Our aim in this study was to investigate the relationship between 25(OH)D levels and BPPV.

METHODS

This retrospective, case-controlled study included 52 patients with posterior canal BPPV and 52 controls aged 18 to 80 years. Age, sex, serum calcium, corrected calcium, and 25(OH)D levels of the BPPV and control group were compared.

RESULTS

Twenty-three of the patients were male (44.2%) and 29 were female (55.8%). The average age was 55.6 years. The 25(OH)D level was 15.3 ng/mL in the BPPV group and 20.2 ng/mL in controls. There was no significant difference in 25(OH)D and albumin-corrected calcium values (P = .394; P = .084, respectively). In 80.7% of the BPPV group and 61.5% of the controls, 25(OH)D levels were 20 ng/mL and below. 25 hydroxyvitamin D deficiency was found statistically significantly more frequently in patients with BPPV (P = .030).

CONCLUSION

In our study, serum 25(OH)D levels were found to be lower in patients with BPPV, and the rate of vitamin D deficiency was higher in these patients. Based on these results, it is recommended to examine the 25(OH)D levels of patients with BPPV at the time of diagnosis.

Eye movements in demyelinating, autoimmune and metabolic disorders

PURPOSE OF REVIEW

In the last three decades, the use of eye movements and vestibular testing in many neurological disorders has accelerated, primarily because of practical technologic developments. Although the acute vestibular syndrome is a prime example of this progress, more chronic neurologic and systemic disorders have received less attention. We focus here on recent contributions relating vestibular and ocular motor abnormalities in inflammatory, demyelinating, metabolic, and peripheral nervous system disorders RECENT FINDINGS: Vestibular abnormalities have been identified in acute demyelinating neuropathies (AIDP), in novel genetic mutations responsible for CANVAS (cerebellar ataxia, neuropathy vestibular areflexia syndrome), and in other inherited neuropathies (variants of Charcot-Marie-Tooth disease). In addition, there are differentiating characteristics between the most common CNS demyelinating disorders: multiple sclerosis and neuromyelitis optica (NMO). We summarize new information on Vitamin D metabolism in benign paroxysmal positional vertigo (BPPV), followed by a brief review of the vestibular and ocular motor findings in Wernicke's encephalopathy. We conclude with findings in several paraneoplastic/autoimmune disorders.

SUMMARY

This literature review highlights the impact of a careful vestibular and ocular motor evaluation in common neurologic disorder, not only for the initial diagnosis but also for monitoring disease and rehabilitation. A careful examination of eye movements and vestibular function, supplemented with new video techniques to quantify the findings, should be part of the standard neurologic examination.

Clinical Characteristics of Patients with Persistent Apogeotropic and Persistent Geotropic Direction-Changing Positional Nystagmus

Background and Purpose

This study aimed to determine the clinical features, diagnosis, and treatment of patients with persistent geotropic (pG) and persistent apogeotropic (pAG) direction-changing positional nystagmus (DCPN).

Methods

This retrospective study included 30 patients with pG-DCPN and 44 patients with pAG-DCPN. All patients underwent neurological and neurotological examinations, including an evaluation of gaze-evoked nystagmus, eye-movement tests, and assessments of limb ataxia and balance, as well as magnetic resonance imaging to exclude central causes. The characteristics of positional nystagmus were detected using the supine roll test (SRT) and bow-and-lean test (BLT). The null point (NP) at which the nystagmus disappeared was determined. All patients were treated with the barbecue maneuver, and treatment efficacy was evaluated immediately, 1 week, and 1 month after treatment.

Results

The history of diseases associated with atherosclerosis, peripheral vestibular disorders, otological disease, and migraine differed significantly between patients with pG-DCPN and pAG-DCPN. The affected sides of persistent horizontal DCPN can be determined using the SRT and the BLT, while determining the second NP and vestibular function as well as performing an audiological evaluation can be used to assist in identifying the affected side. The efficacy rates immediately and 1 week after treatment with the barbecue maneuver were higher in patients with pAG-DCPN than in patients with pG-DCPN.

Conclusions

pAG-DCPN was more compatible with the characteristics of cupulolithiasis, and pG-DCPN was more likely to be associated with a light cupula rather than canalolithiasis. pAG-DCPN was more likely to be accompanied by a disease associated with atherosclerosis, while pG-DCPN was often accompanied by autoimmune-related diseases and a history of migraine. The associations between pAG-DCPN, pG-DCPN, and the above-mentioned diseases need to be clarified further. The canalith-repositioning maneuver was effective in patients with pAG-DCPN and ineffective in patients with pG-DCPN, but most cases of pG-DCPN are self-limiting.

Relationship between calcium metabolism and benign paroxysmal positional vertigo in north Sardinia population

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) has a reported recurrence ranging from 26.8 to 50%. Osteoporosis and Vitamin D deficiency seems to have an impact on recurrence of BPPV.

OBJECTIVE

to evaluate the impact of osteoporosis and Vitamin D deficiency on recurrence of BPPV.

METHODS

73 consecutive patients were divided in two groups according to the presence (group 1) or absence (group 0) of a recurrent episode. BMD, femoral and lumbar T-scores and Vitamin D levels were recorded. Statistical analysis was performed to investigate correlations.

RESULTS

patients in group 1 had statistically significant lower values of both femoral (-1,62±1,06 vs. -0,53±1,51; p = 0,001), lumbar T-score (-2,10±1,19 vs -0, 53±1.51, p = 0.001) and Vitamin D (19.53±15.33). The values of femoral T-score and Vitamin D could be combined in a model able to properly classify 65.8% of the cases (p = 0.002) as isolated or recurrent BPPV, with high accuracy (AUC 0.710 [0.590 -0.830]).

CONCLUSION

present data show a probable correlation between osteoporosis and Vitamin D with recurrent BPPV.

Cerebellar infarction presenting with isolated positional vertigo: differentiating factors for benign paroxysmal positional vertigo

BACKGROUND

Isolated central positional vertigo (CPV) due to cerebellar infarction is often difficult to differentiate from benign paroxysmal positional vertigo (BPPV). Here, we aimed to evaluate whether vascular risk factors and serum vitamin D level can differentiate between positional vertigo types.

METHODS

A total of 78 consecutive patients were consecutively enrolled from January 2017. All CPV patients had a National Institutes of Health Stroke Scale score of 0 and cerebellar infarctions confirmed by brain MR imaging. Vascular risk factors and serum 25-hydroxyvitamin D levels were compared between the two groups of patients.

RESULTS

The proportion of men was higher in the CPV than in the BPPV group (p = 0.004). Atrial fibrillation was common in the CPV group on univariate analysis (p = 0.046). However, there were no independent differentiating factors between the two groups. The proportion of patients according to the number of risk factors was significantly different between the two groups (linear by linear association test, p = 0.02). The mean serum 25-hydroxyvitamin D level did not differ. Also, the proportions of vitamin D insufficiency and deficiency did not differ significantly between the two groups.

CONCLUSIONS

Increased number of vascular risk factors including male sex suggested more CPV than BPPV. However, the serum vitamin D level was below the normal range in both groups. Our results demonstrate that serum vitamin D level has little value in the differential diagnosis of positional vertigo. Efforts to identify differentiating factors are warranted, and accumulating evidences including our research may lead to a diagnostic algorithm for isolated positional vertigo.

Clinical Characteristics of Patients With Benign Paroxysmal Positional Vertigo Diagnosed Based on the Diagnostic Criteria of the Bárány Society

Objectives: To analyze the clinical characteristics of patients with benign paroxysmal positional vertigo (BPPV) diagnosed based on the diagnostic criteria of Bárány Society, verify the clinical application value of the diagnostic criteria, and further explore the clinical problems associated with the diagnosis of possible BPPV.

Methods: A total of 481 patients with BPPV who were admitted from March 2016 to February 2019 were included. All patients were diagnosed by the Dix-Hallpike, straight head hanging and supine roll tests, the nystagmus was recorded using videonystagmography. For patients with possible BPPV (uncertain diagnosis), particle repositioning therapy and follow-up diagnosis were used to further clarify diagnosis.

Results: Based on Bárány Society's diagnostic criteria for BPPV, the distribution characteristics of different BPPV types were as follows: 159 (33.1%) patients had posterior canal BPPV-canalolithiasis (PC-BPPV-ca), 70 (14.6%) patients had horizontal canal BPPV-ca (HC-BPPV-ca), 55 (11.4%) patients had spontaneously resolved-probable-BPPV (Pro-BPPV), and 53 (11.0%) patients had HC-BPPV-cupulolithiasis (HC-BPPV-cu). In emerging and controversial BPPV, 51 (10.6%) patients had multiple canal BPPV (MC-BPPV), 30 (6.2%) patients had PC-BPPV-cu, and 19 (4.0%) patients had anterior canal BPPV-ca (AC-BPPV-ca), 44 (9.1%) patients had possible-BPPV (Pos-BPPV). Among the 44 patients with Pos-BPPV, 23 patients showed dizziness/vertigo without nystagmus during the initial positional test, five patients were possible MC-BPPV, four patients had persistent geotropic positional nystagmus lasting > 1 min when lying on both sides, and were considered to have Pos-HC-BPPV, four patients showed apogeotropic nystagmus when lying on one side, and were considered to have possible short-arm HC-BPPV, four patients showed geotropic nystagmus when lying on one side, and were considered to have Pos-HC-BPPV, three patients had down-beating nystagmus, lasing > 1 min, were considered to have Pos-AC-BPPV-cu. One patient showed transient apogeotropic positional nystagmus on both sides during the supine roll test, and was diagnosed with possible anterior arm HC-BPPV.

Conclusions: PC-BPPV-ca is the most common among patients with BPPV, followed by HC-BPPV-ca. In emerging and controversial BPPV, MC-BPPV, and Pos-BPPV were more common. For the diagnosis of Pos-BPPV, a combination of the history of typical BPPV, particle repositioning therapy and follow-up outcome is helpful to clarify the diagnosis.

Correlation Between Benign Paroxysmal Positional Vertigo and 25-hydroxyvitamin D

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

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

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

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

Clinical characteristics of patients with multi-canal benign paroxysmal positional vertigo

Introduction

Multi-canal benign paroxysmal positional vertigo is considered to be a rare and controversial type in the new diagnostic guidelines of Bárány because the nystagmus is more complicated or atypical, which is worthy of further study.

Objective

Based on the diagnostic criteria for multi-canal benign paroxysmal positional vertigo proposed by International Bárány Society, the study aimed to investigate the clinical characteristics, diagnosis and treatment of multi-canal benign paroxysmal positional vertigo.

Methods

A total of 41 patients with multi-canal benign paroxysmal positional vertigo were included and diagnosed by Roll, Dix-Hallpike and straight head hanging tests. Manual reduction was performed according to the involvement of semicircular canals.

Results

Among the 41 cases, 19 (46.3%) patients showed vertical up-beating nystagmus with or without torsional component and geotropic, apogeotropic horizontal nystagmus, and were diagnosed with posterior-horizontal canal. 11 (26.8%) patients showed vertical up-beating nystagmus with torsional component on one side and vertical down-beating nystagmus with or without torsional component on the other side during Dix-Hallpike test or straight head hanging test and were diagnosed with posterior-anterior canal benign paroxysmal positional vertigo 9 (26.8%) patients showed vertical down-beating nystagmus with or without torsional component and geotropic, apogeotropic horizontal nystagmus, and were diagnosed with anterior-horizontal canal 2 (4.9%) patients showed vertical geotropic torsional up-beating nystagmus on both sides and were diagnosed with bilateral posterior canal benign paroxysmal positional vertigo. High correlation between the sides with reduced vestibular function or hearing loss and the side affected by Multi-canal benign paroxysmal positional vertigo was revealed (contingency coefficient = 0.602, p = 0.010). During one-week follow up, nystagmus/vertigo has been significantly alleviated or disappeared in 87.8% (36/41) patients.

Conclusion

Posterior-horizontal canal benign paroxysmal positional vertigo was the most common type. Multi-canal benign paroxysmal positional vertigo involving anterior canal was also not uncommon. Caloric tests and pure tone audiometry may help in the determination of the affected side. Manual reduction was effective in most of Multi-canal benign paroxysmal positional vertigo patients.

Otoconia degeneration as a consequence of primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a common endocrine condition which disrupts physiologic calcium regulation. PHPT causes persistent hypercalcemia via the elevated and constant secretion of parathyroid hormone. Due to the effects of parathyroid hormone on target organs such as the bones, kidneys and gastrointestinal tract, untreated PHPT can lead to complications such as decreased bone mineral density, nephrolithiasis, and chronic abdominal pain, respectively. Given PHPT's drastic effect on calcium metabolism, it is likely that the condition also affects other organ systems, such as the inner ear, which rely on calcium for normal structure and function. Specifically, the saccule and utricle have otoconia made of calcium carbonate deposited on a protein framework. We hypothesize that PHPT, the epitome calcium disorder, can cause otoconia degeneration, one manifestation of which is benign paroxysmal positional vertigo (BPPV). As a preliminarily test of this hypothesis, we measured the levels of otolin-1, an inner ear glycoprotein found in the otoconia protein framework and a proposed biomarker for otoconia degeneration in patients with PHPT. We found a positive linear relationship between PTH (parathyroid hormone) and otolin-1 levels (R² = 0.53) and total calcium and PTH levels (R² = 0.32). These findings suggest that both PTH and total calcium levels affect otolin-1 levels, implying that the calcium dysregulation caused by PHPT may contribute to the otoconia breakdown and may be associated with inner ear disorders such as BPPV.

[The impairment of bone-mineral metabolism in the development of benign paroxysmal positional vertigo]

Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of systemic vertigo in clinical practice. The results of recent research demonstrated the decrease of bone mineral density, level of vitamin D and estrogen in blood serum in patients with BPPV. In summary these data points at the relationship between osteoporosis/osteopenia and BPPV. This association is most obvious in menopausal women and in those with recurrent BPPV. Patients with recurrent BPPV should undergo investigation for osteoporosis/osteopenia. Treatment of bone-mineral metabolism allows decreasing the frequency of BPPV recurrence, however more research is needed in this area.

Bone mineral density and serum 25-hydroxyvitamin D in subtypes of idiopathic benign paroxysmal positional vertigo

Although the etiology of benign paroxysmal positional vertigo (BPPV) is idiopathic in most cases, the association of osteoporosis or vitamin D deficiency with BPPV has attracted much interest recently. While it is generally accepted that osteoporosis or vitamin D deficiency is related to the occurrence and/or recurrence of BPPV, the difference in serum vitamin D level and bone mineral density (BMD) among different subtypes of BPPV has not been investigated. We aimed to compare T-score of BMD score and serum 25-hydroxyvitamin D level among idiopathic BPPV patients with a different subtype. This study included 117 consecutive patients with idiopathic BPPV (26 men and 91 women; mean age, 55 ± 11 years; age range, 25 to 78 years) who underwent blood sampling for serum 25-hydroxyvitamin D level measurement and bone mineral densitometry of the anterior-posterior lumbar spine and femur between April 2018 and February 2019. Among 117 patients, 49 were diagnosed with posterior semicircular canal (PSCC) BPPV, 24 were diagnosed with lateral semicircular canal (LSCC) canalolithiasis, and 44 were diagnosed with LSCC cupulolithiasis. The mean T-score of BMD was -1.5 ± 0.9 in PSCC BPPV, -1.5 ± 1.3 in LSCC canalolithiasis, and -1.5 ± 1.1 in LSCC cupulolithiasis, which was not significantly different (p = 0.998, One-way ANOVA test). The mean level of 25-hydroxyvitamin D was 22.5 ± 10.6 ng/ml in PSCC BPPV, 26.8 ± 16.0 ng/ml in LSCC canalolithiasis, and 25.4 ± 9.6 ng/ml in LSCC cupulolithiasis, which was not significantly different (p = 0.262, One-way ANOVA test). The proportion of osteoporosis/osteopenia or vitamin D deficiency/insufficiency did not show significant difference among idiopathic BPPV patients with different subtypes, and findings of this study indicate that either serum level of vitamin D or T-score of BMD is not a distinguishable characteristic among different subtypes of BPPV.

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.

Decreased 25-Hydroxyvitamin D Levels in Patients With Vestibular Neuritis

Objective: Vestibular neuritis (VN) is characterized by acute onset of vertigo, nausea, and vomiting, without auditory or other neurological symptoms. Although the pathogenesis of VN is not yet clear, many studies have shown that a pro-inflammatory environment can lead to the induction and progression of the disease. Considering the importance of vitamin D in modulating the activation, proliferation, and differentiation of inflammatory physiological processes, we hypothesized that decreased serum vitamin D may be associated with the development of VN. In this study, we evaluated serum levels of 25-hydroxyvitamin D [25(OH)D] in patients presenting acutely with VN and healthy controls and investigated the possible correlation of serum 25(OH)D levels with VN.

Methods: A total of 59 consecutive patients diagnosed with VN within 7 days of symptom onset and 112 age- and sex-matched healthy controls referred to Hwa Mei Hospital, University of Chinese Academy of Science, between March 2017 and March 2019 were recruited. Demographic and clinical data, such as age, sex, height, weight, living habits, ongoing health problems, and medication history, for all subjects were recorded, and levels of 25(OH)D were measured and compared.

Results: Serum levels of 25(OH)D were lower in patients with VN than in controls (19.01 ± 6.53 vs. 22.94 ± 6.74 ng/ml, p < 0.001). Patients with VN had a higher frequency of vitamin D deficiency (61.0 vs. 34.8%, P = 0.001) than did controls. Regression analyses demonstrated that vitamin D deficiency was associated with VN, with an odds ratio of 4.53 (95% CI = 1.342–15.279, P = 0.015).

Conclusion: This prospective study is the first to evaluate serum 25(OH)D levels in patients with VN and found that decreased serum 25(OH)D may be associated with VN occurrence.

Benign paroxysmal positional vertigo in Meniere's disease: systematic review and meta-analysis of frequency and clinical characteristics

There is a recognized association of Meniere's disease (MD) and benign paroxysmal positional vertigo (BPPV). However, the frequency and clinical characteristics of BPPV in MD are unclear. The aim of this review was to determine the mean frequency and clinical features of BPPV in MD. Three databases were searched: MEDLINE, PubMed and Google Academia. Studies reporting the frequency of BPPV in MD were pooled. A total of 4198 references were identified, of which 20 studies were considered eligible. The pooled frequency of BPPV in MD was 14% (95% CI 9-18%). It was 38% (95% CI 26-49%) in longitudinal studies and 8% (95% CI 6-11%) in cross-sectional ones. BPPV comorbid with MD was mostly observed in the ear affected by hydrops, in females, in patients with more advanced disease. Canalolithiasis of the horizontal semicircular canal was more common in patients with BPPV associated with MD than in idiopathic BPPV. BPPV in MD was more prone to recurrence and required more canal repositioning maneuvers.