An Abbreviated Diagnostic Maneuver for Posterior Benign Positional Paroxysmal Vertigo

Bow and Lean Test for Rare Variants of Vertical Semicircular Canal BPPV

OBJECTIVE

The objective of this study was to assess the clinical significance of the Bow and Lean Test (BLT) for the diagnosis of different variants of vertical canal Benign Paroxysmal Positional Vertigo (BPPV). BLT is commonly used for diagnoses of lateral semicircular canal (LSC) BPPV. However, vertical nystagmus in the BLT may indicate the presence of other variants such as PSC-BPPV.

METHODS

567 patients with vertical canal BPPV were recruited. Patients with anterior semicircular canal (ASC) or PSC-BPPV were weekly examined until the negativization of BPPV. Nystagmus characteristics during BLT were analyzed.

RESULTS

Of 567 patients with vertical canal BPPV, 1.4% had ASC-BPPV. BLT was positive in 155 patients, showing patterns like down-beating nystagmus in bowing and no nystagmus in leaning (15.52% of patients), and down-beating in bowing and up-beating in leaning (6.17%), which was predominantly present in PSC-canalolithiasis. Statistically significant differences were observed in the direction of nystagmus provoked by BLT in PSC-BPPV subtypes. No significant differences were found in nystagmus latency or duration during BLT positions. Among BPPV subtypes, there was a significant difference in nystagmus duration and latency, especially between cupulolithiasis and other variants. BLT's sensitivity was 0.93 in bowing and 1 in a leaning position, while specificity was 0.93 and 0.82 respectively.

CONCLUSION

Beyond the LSC, the BLT has expanded to other variants. However, study results differ likely due to variations in patient characteristics and test execution. Currently, no specific features for ASC have been found to differentiate it from PSC-BPPV limiting the test's use for this variant.

LEVEL OF EVIDENCE

3, according to Oxford Center for Evidence-Based Medicine Laryngoscope, 134:2405-2410, 2024.

Is it possible to diagnose Posterior Semicircular Canal BPPV from the sitting position? The role of the Head Pitch Test and the upright tests along the RALP and LARP planes

PURPOSE

The diagnosis of benign paroxysmal positional vertigo (BPPV) involving the posterior semicircular canal (PSC) is traditionally entrusted to positioning tests where patients are rapidly brought in the supine position. This prospective study aims to define the role of a diagnostic protocol for PSC-BPPV including only upright tests.

MATERIALS AND METHODS

109 patients with PSC-BPPV were enrolled. The Head Pitch Test (HPT) was carried out first. If uneventful, the patient's head was turned 45° to each side and bent back-and-forth along the plane aligning either with the right anterior-left posterior (RALP) or left anterior-right posterior (LARP) canals, thus performing the upright RALP / upright LARP (uRALP/uLARP) test. Nystagmus observed was used to predict the diagnosis, which was therefore confirmed by Dix-Hallpike tests.

RESULTS

PSC-BPPV could be correctly diagnosed in 75.2% of cases with the sole HPT and in 87.2% of cases by adding the uRALP/uLARP test (Upright Protocol). The time elapsed from symptoms onset was closely related to the protocol sensitivity, as it reached 100% (64/64) in acute patients while decreased to 68.9% (31/45) in cases evaluated after 7 days (p < 0.001).

CONCLUSIONS

Upright maneuvers could correctly diagnose PSC-BPPV in most cases. uRALP/uLARP test demonstrated to improve the sensitivity of the HPT, mainly in recent-onset BPPV.

Diagnostic Value of Straight Head Hanging in Posterior Canal Benign Paroxysmal Positional Vertigo

Background and Purpose

To determine the diagnostic value of straight head hanging (SHH) in benign paroxysmal positional vertigo involving the posterior semicircular canal (PC-BPPV).

Methods

We retrospectively included 62 patients (age=56.2±15.0 years, 47 female) with unilateral PC-BPPV who underwent both the Dix-Hallpike maneuver and SHH before receiving canalith repositioning therapy (CRT) between September 2017 and July 2020 at the Dizziness Center of Seoul National University Bundang Hospital in South Korea (16 patients, 25.8%) or the Neurology Outpatient Clinic of Aerospace Central Hospital in China (46 patients, 74.2%). SHH was performed before (n=29, group A) or after (n=33, group B) the Dix-Hallpike maneuver.

Results

Torsional upbeat nystagmus typical of PC-BPPV was induced during SHH in 52 (83.9%) patients, and the incidence of this type of positional nystagmus did not differ between the groups A and B (79.3% vs. 87.9%, p=0.569). The maximum slow-phase velocity of the induced upbeat nystagmus was higher during SHH than during the Dix-Hallpike maneuver toward the lesion side [range=2.0–60.0°/s (median=18.5°/s) vs. range=2.7–40.0°/s (median=13.4°/s), p<0.001]. Reversal of the positional nystagmus was observed upon resuming the sitting position after SHH in 47 (75.8%) patients and after the Dix-Hallpike maneuver in 54 (87.7%) patients, with no significant difference between the groups (p=0.082).

Conclusions

SHH is effective for diagnosing PC-BPPV. Given its simplicity, SHH may be performed before the Dix-Hallpike maneuver, and CRT may be attempted thereafter when the typical positional nystagmus for unilateral PC-BPPV is induced during SHH.

The efficacy of a modified Dix-Hallpike test with a pillow under shoulders

BACKGROUND

Dix-Hallpike (DH) test is sometimes done in a modified or reduced manner in a clinical setting. However, there has been no study that evaluated the reliability of this modified test.

OBJECTIVES

The purposes of this study were to determine whether the efficacy of a modified DH test, named the 'pillow under shoulders' test, was equivalent to the standard DH test and to assess the difference in patient discomfort between the two methods.

METHODS

Randomized controlled study at three academic referral hospitals, conducted in compliance with the CONSORT statement. Patients suspected for BPPV based on symptoms were randomly assigned to Group A or Group B. Patients in Group A received a standard DH test initially, followed by a modified DH test with a pillow under shoulders. Patients in Group B also received the two tests, but in the reverse order. The diagnostic results of both tests and patients' subjective scoring for uneasiness (discomfort, pain, anxiety) were statistically analyzed.

RESULTS

McNemar's test and Kappa statistics showed a statistically equivalent diagnostic value between standard and modified DH tests (Cohen's kappa = 0.823 and McNemar P = 0.18). The modified DH test had high sensitivity (95.5%) and fairly good specificity (87.9%). There was no statistical significance in the patients' subjective scoring for uneasiness between the two methods, although most patients reported less inconvenience after the modified DH test compared to the standard DH test.

CONCLUSIONS

The modified version of the standard DH test, the 'pillow under shoulders' method, may be a reliable, comfortable option to diagnose vertical canal BPPV. We suggest that this method can be used when head hanging is not feasible or sufficient for the standard DH test.

Abecedario del examen vestibuloespinal. Revisión bibliográfica

Introducción y objetivo: Durante las largas cuarentenas impuestas en el mundo por la pandemia de COVID-19 los médicos hemos empezado a usar con mayor asiduidad la modalidad de consulta virtual. La neurootología no ha sido una excepción en este contexto y usando el mecanismo de las videollamadas hemos podido dar atención y contención a un buen número de pacientes durante este período. Por esta razón y basados en la experiencia singular de este periodo, hemos diseñado un examen sistemático, basado en pruebas vestíbulo-espinales simples y presentadas en forma nemotécnica (abecedario). Sobre la base de nuestra experiencia y con una revisión de la literatura se intenta demostrar la etiología y topografía vestibular de los hallazgos. Método: Revisión narrativa. Para la búsqueda de la bibliografía se utilizó la metodología de revisión sistemática de documentos en metabuscadores y bases de datos. Periodo analizado del 2001 al 2019, en diversas revistas científicas. Resultados: El examen se dividió en cuatro pasos de acuerdo con las cuatro primeras letras del alfabeto: Ataxia (gradación), Bárány (desviación de los índices), Cefálico (tilt o inclinación cefálica de la cabeza en relación con el tronco) y Desviación (desviación oblicua de los ojos Test de skew). Discusión: Se plantea el uso de la mnemotecnia abecedario para ordenar el examen vestíbulo espinal en los pacientes con afección del sistema vestibular, de manera simple y práctica, permitiendo la modalidad virtual. Conclusiones: Este sencillo abecedario vestíbulo-espinal permite, asociado a un interrogatorio exhaustivo, realizar un examen vestibular eficaz por medios virtuales, separar eficazmente lesiones centrales de periféricas en cuadros vestibulares agudos con alta sensibilidad y especificidad y finalmente hacer un topodiagnóstico del lado de lesión vestibular.

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

PURPOSE

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

METHODS

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

RESULTS

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

DISCUSSION

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