Diagnosis and Treatment of Anterior-Canal Benign Paroxysmal Positional Vertigo: A Systematic Review

Semont maneuver for posterior canal benign paroxysmal positional vertigo: a systematic review of randomized controlled trials

PURPOSE

This review aimed to examine the effects of the Semont maneuver on posterior canal benign paroxysmal positional vertigo (BPPV).

METHODS

PubMed, PEDro, SCOPUS, REHABDATA, EMBASE, and Web of Science were searched comprehensively from inception to January 2024. The Physiotherapy Evidence Database (PEDro) scale was employed to evaluate the quality of the selected studies.

RESULTS

In total, 18 randomized controlled trials met the eligibility criteria. A total of 2237 participants with BPPV (mean age = 58.10 years) were included in this review. Among them, 37.5% were males, and 58% presented with right-sided BPPV. The included studies ranked from 5 to 9 out of 10 (Median = 7), suggesting good to excellent quality on the PEDro scale. The available literature revealed that the Semont maneuver is effective in improving posterior canal BPPV symptoms.

CONCLUSION

The Semont maneuver is considered a standard option for treating posterior canal BPPV, with a high success rate of around 80%. It is suggested as the primary option for managing posterior canal BPPV in individuals who complain of cervical or lumbar problems, severe cardiac or respiratory conditions. Further studies are strongly needed to understand the long-term effects of the Semont maneuver and to identify the recurrence rate.

The Effect of Different Sensory Perturbations on Postural Control and Fall Risk in Benign Paroxysmal Positional Vertigo Patients

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) patients may experience balance problems in various environmental conditions other than positional dizziness. Therefore, there is a need to investigate the postural control abilities and the ability to use sensory inputs in BPPV patients in different conditions.

OBJECTIVE

The aim of this study was to examine the postural control performance of middle-aged adult BPPV patients in easy and difficult balance tasks, the effect of vestibular stimulation on the maintenance of balance, and the risk of falling, by posturographic evaluation in various conditions.

METHOD

A total of 26 patients diagnosed with posterior canal BPPV and 26 controls were included in the study. Sensory Organization Test (SOT), Vestibular Stimulation Test (VST), and fall risk assessment (FRA) were applied to the participants, respectively.

RESULTS

Significant difference was observed in SOT medio-lateral (ML) plane in Conditions 2 and 5 (p < .05). A significant difference was observed in the vestibular score in the SOT ML plane. No significant difference was observed in VST test scores (p > .05). In the FRA test, a significant difference was observed in the energy and gain parameters in the anterio-posterior plane (p < .05).

CONCLUSIONS

The current study examined postural control abilities of patients with BPPV in extensive external conditions and in both planes, using various sensory perturbations and stimulation. It was thought that while BPPV patients were in the active phase of the disease, their postural control skills in the ML plane decreased and they might be at risk of falling.

Effectiveness of brandt-daroff exercises in the treatment of benign paroxysmal positional vertigo: a systematic review of randomized controlled trials

PURPOSE

This review aims to examine the effects of Brandt-Daroff exercises (BDEs) on individuals with posterior canal Benign Paroxysmal Positional Vertigo (BPPV) and to provide recommendations for future research on this topic.

METHODS

PubMed, MEDLINE, PEDro, SCOPUS, REHABDATA, EMBASE, and Web of Science were searched from inception to November 2023. The Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality of the included studies.

RESULTS

In total, ten randomized controlled trials met our eligibility criteria. A total of 880 individuals with BPPV (63.6% females) were included in this review. The included studies were ranked "good quality" on the PEDro scale. The available literature showed that BDEs do not significantly reduce symptoms or promote recovery in people with posterior canal BPPV compared to other interventions, such as Epley and Semont maneuvers.

CONCLUSIONS

The evidence for the effects of BDEs on patients with BPPV is limited. Further high-quality studies with long-term follow-ups are strongly required to investigate the long-term effects of BDEs in posterior canal BPPV, define the optimal application of BDEs, and identify the factors associated with treatment response and recovery.

Semicircular canals are long in patients with benign paroxysmal positional vertigo

OBJECTIVE

To search for any morphological variation contributing to aetiopathogenesis and the diagnosis of benign paroxysmal positional vertigo, we measured the sizes of the semicircular canals in patients with and without benign paroxysmal positional vertigo using multidetector computed tomography.

METHODS

Cranial bone computed tomography images of 30 benign paroxysmal positional vertigo patients and 30 control patients were acquired with a 128-slice computed tomography scanner and a transverse plane with a thickness of 0.67 mm. The inner diameter, height and width of the canals were measured.

RESULTS

The width of the anterior semicircular canals, and the width and height of the posterior semicircular canals of the affected ears in benign paroxysmal positional vertigo patients (n = 30) were significantly greater than in the control patients (n = 90; p = 0.001, p = 0.023, p = 0.003, respectively).

CONCLUSION

In benign paroxysmal positional vertigo patients, the posterior and anterior semicircular canals are longer than those in people without benign paroxysmal positional vertigo. These morphological changes may contribute to elucidating the aetiopathogenesis and be used as a radiological sign for diagnosis of benign paroxysmal positional vertigo disease.

Comparing Epley Maneuver, Betahistine, and Dimenhydrinate in the Treatment of Benign Paroxysmal Positional Vertigo: A Prospective Study

Although the Epley maneuver is considered the primary treatment in BPPV, anti-vertigo medications are effective in residual symptoms. This study was designed to compare betahistine and dimenhydrinate plus the Epley maneuver and the Epley maneuver alone. This prospective cohort study was performed in Mashhad, Iran, from 2013 to 2015. 90 adult patients diagnosed with BPPV in hospitals and ENT clinics were selected through convenience sampling. Patients received betahistine 8 mg TDS or dimenhydrinate 50 mg once daily plus Epley or the Epley alone for four weeks. SF-36 and the DHI were used before and after the treatment. 49 were females (54.4%). The mean (SD) age was 47.9 (8.7) years. There was no significant difference between the groups in age (P = 0.753) and gender (P = 0.050).There were significant differences in all areas of SF-36 except for social activities in the dimenhydrinate group. There was a marginally significant difference between the betahistine and dimenhydrinate groups in role limitation due to physical health problems (P = 0.046). There were significant differences between the females and males in emotional well-being before and after treatment in the dimenhydrinate group (P = 0.014) and in terms of role limitation due to physical health problems in the Epley maneuver group (P = 0.022). Older patients in the betahistine group had better social activities after treatment (P = 0.048). In severe forms of BPPV, betahistine or dimenhydrinate might effectively reduce the symptoms.

Treatment of posterior Benign Paroxysmal Positional Vertigo is efficient and safe with a new Mechanical Rotational Chair

Background

Benign paroxysmal positional vertigo (BPPV) is the most predominant vestibular disease. Previously, in the management of BPPV, both therapeutic and diagnostic benefits with mechanical rotation chairs (MRCs) have been reported. However, no previous studies have examined the efficacy of MRC treatment with a fairly new MRC.

Methods

Randomized three-armed parallel open-labeled prospective clinical trial. One hundred and five patients diagnosed with posterior BPPV underwent diagnostics and treatment with an MRC. Patients were randomized to either a Semont maneuver, an Epley maneuver or a 360-degree backwards somersault maneuver. Primary endpoint was to evaluate the efficiency of an MRC in the treatment of posterior BPPV with three separate treatment modalities. Secondary objectives included subjective vertigo assessments.

Results

BPPV treatment with this MRC is very efficient with success rates up to 97.1 percent. The number of treatments required to achieve complete resolution of both objective findings and subjective symptoms was 1.5. Almost 47 percent of patients experienced complete resolution of both subjective and objective measures following one (first) treatment. All Dizziness Handicap Inventory scores decreased significantly post-treatment.

Conclusion

Treatment of posterior BPPV, with the MRC used in this study, was very efficient with both the Semont, the Epley, and the 360-degree backwards somersault maneuver. Based on the findings in this study, this fairly new MRC seems both effective and safe to use.

Treatment Efficacy of Various Maneuvers for Lateral Canal Benign Paroxysmal Positional Vertigo With Apogeotropic Nystagmus: A Randomized Controlled Trial

OBJECTIVES

The aim of this study was to determine the most effective treatment approach by comparing the impacts of various otolith reduction techniques in patients with apogeotropic lateral semicircular canal benign paroxysmal positional vertigo (LC-BPPV).

METHODS

We performed a multicenter randomized prospective study from January to December 2015, involving 72 consecutive patients with apogeotropic LC-BPPV. The patients were divided into three treatment groups: therapeutic head-shaking (group A), the Gufoni-Appiani maneuver (group B), and the cupulolith repositioning maneuver (CuRM; group C). Each group underwent evaluation and treatment up to the fourth week. Treatment success was defined as the disappearance of positional vertigo and nystagmus.

RESULTS

This study included 72 patients (49 male and 23 female), with a mean (±standard deviation) age of 55.4±13.5 years. The mean duration of vertigo experienced prior to treatment was 3.9±4.4 days. The mean latency and duration of nystagmus were 2.7±3.0 seconds and 47.9±15.8 seconds, respectively. The overall treatment frequency was 2.0±0.9. The number of treatments differed significantly among the three groups (P<0.05). After 4 weeks, the success rates for groups A, B, and C were 90.5%, 92.3%, and 100%, respectively. No significant difference was observed in the success rate across treatment.

METHODS

and periods (P>0.05). However, CuRM was the only method with a 100% treatment success rate.

CONCLUSION

While no clear difference was observed among the three treatments for LC-BPPV, CuRM was found to be superior to the other approaches in the long term.

Global research trends in benign paroxysmal positional vertigo: a bibliometric analysis

Background

Benign paroxysmal positional vertigo is the most common disease in which vertigo is the main clinical manifestation, and it has become a global medical problem, affecting a wide range of areas and seriously affecting the quality of human life.

Objective

This article presents an analysis of the current characteristics of BPPV-related research and summarizes the current hot topics and trends, with the goal of inspiring future research into the prevention and treatment of BPPV, thereby improving the differential diagnosis and prevention of peripheral vertigo.

Methods

A bibliometric approach was used to collect 1,219 eligible studies on BPPV from four databases-PubMed, Embase, Scopus, and Web of Science-published between 1974 and 2022. The characteristics and status of the accumulated scientific output were processed using R and VOSviewer so that we could visualize any trends or hotspots.

Results

The results showed a significant increase in the annual number of publications, with an average annual growth rate of 21.58%. A possible reason for the especially pronounced peak in 2021 was an increase in the prevalence of BPPV as a result of COVID-19. The new coronavirus became a focus of research in 2021. A total of 3,876 authors (of whom 1,097 were first authors) published articles in 307 different journals; 15.7% of the articles were published in Acta Oto-Larygologica, Otology and Neurotology, and Frontiers in Neurology. Acta Oto-Laryngologica was well ahead of the other journals in terms of growth rate and number of articles published. American scholars generated the largest number of articles overall, and the USA was involved in the greatest number of international collaborations, followed by Italy and China. The themes of the research centered around three topics, namely the treatment of BPPV, its influencing factors, and diagnosis.

Conclusions

There has been a major increase in BPPV-related research over the last 50 years, leading to an increase in related articles and rapid development of the field. Key directions for future research include the improvement of individualized treatment for residual symptoms after initial treatment of BPPV among the elderly; effective control of comorbidities such as osteoporosis; and secondary inner ear disease, such as Ménière's disease.

Characteristics of Benign Paroxysmal Positional Vertigo in Young Children

OBJECTIVES

This study aimed to determine the clinical characteristics of benign paroxysmal positional vertigo (BPPV) in young children.

STUDY DESIGN

Retrospective case review.

METHODS

All children <10 years old that have been diagnosed with BPPV at our pediatric vestibular program between December 2012-July 2021 were selected. Clinical features were identified by medical record review, including demographics, comorbidities, canal involvement, response to treatment, and incidence of recurrence.

RESULTS

A total of 34 children were diagnosed with BPPV with a mean age of 7.9 years old (SD ± 1/7; range 5-9) at the time of diagnosis and a male:female ratio of 1:1. Involved semicircular canals included posterior in 82% (n = 28), horizontal in 41% (n = 14), and superior in 24% (n = 8) of patients, respectively. Comorbid diagnoses included migraine (n = 14), concussion (n = 10), acute vestibular syndrome (n = 4), and persistent postural perceptual dizziness (n = 6). Recurrence with initially confirmed resolution occurred in 10 patients (29%) with a mean of 2.5 recurrences per patient (SD: 2.2; range 1-8). A family history of vertigo or migraine was identified in 11 and 17 patients, respectively.

CONCLUSIONS

BPPV is a cause of vertigo in children that may be overlooked. A relatively high proportion of patients demonstrated horizontal or superior canal involvement, recurrence, and additional comorbid causes of dizziness. Thus, providers evaluating young children with dizziness should perform diagnostic maneuvers to evaluate BPPV of all semicircular canals and continue to monitor children after successful treatment for recurrence.

LEVEL OF EVIDENCE

4, Case Series Laryngoscope, 133:694-699, 2023.

Less talked variants of benign paroxysmal positional vertigo

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

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

Objective

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

Study Design

Retrospective cohort study.

Setting

Tertiary referral center.

Patients

Adults (n = 27) with posterior canal BPPV.

Interventions

Single CRM with Frenzel goggles.

Main Outcome Measures

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

Results

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

Conclusions

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

Bilateral Dysfunction of Otolith Pathway in Patients With Unilateral Idiopathic BPPV Detected by ACS-VEMPs

Objective

To observe the functional status of the otolith pathway in patients with unilateral idiopathic benign paroxysmal positional vertigo (BPPV) by combining air-conducted sound elicited cervical vestibular-evoked myogenic potential (ACS-cVEMP) and ocular vestibular-evoked myogenic potential (ACS-oVEMP).

Methods

One hundred and eighty patients with BPPV were recruited for conventional cVEMP and oVEMP tests. The abnormal rates of VEMPs were compared between BPPV patients and control participants.

Results

The abnormal rates of cVEMP and oVEMP in BPPV patients were 46.7% (84/180) and 57.2% (103/180) in affected ears, respectively, and 45.0% (81/180) and 56.7% (102/180) in unaffected ears, respectively; both were significantly higher than the abnormal rates of cVEMP and oVEMP in normal control ears. Compared with normal subjects, the cVEMP response rate was lower in affected and unaffected ears in BPPV patients. The abnormal rates of cVEMP and oVEMP were 48.1% (76/158) and 57.6% (91/158) in patients with posterior semicircular canal BPPV, and 36.4% (8/22) and 54.5% (12/22) in lateral semicircular canal BPPV. There was no significant difference in VEMP abnormalities between posterior semicircular canal BPPV and lateral semicircular canal BPPV.

Conclusion

The prevalence of abnormal cVEMPs and oVEMPs in both affected and unaffected ears of patients with BPPV was significantly higher than that observed in the control group. The pathological mechanism of unilateral idiopathic BPPV may be associated with bilateral degeneration of otolith pathways.

Clinical Study of BPPV and the Effectiveness of Canalolith Repositioning Manoeuvre in Subjects of BPPV

Vertigo is an illusion of motion, either of one self or of the environment. Vertigo in BPPV is a very devastating experience for the patient who experiences it. However, it can be reversible with vestibular rehabilitation, with very good results. A study on 72 patients attending Otoneurology clinic in our hospital, diagnosed as BPPV with history and examination were subjected to DHI (Dizziness Handicap Index) questionnaire prior to and after intervention and results were analyzed. BPPV is more commonly seen in elderly individuals above 45 yrs, females and posterior semi circular canal. A significant improvement was noted in all the three components of DHI index in patients treated with CRM (Canalolith Repositioning Manoeuver) when compared to the patients who received only reassurance. CRM is a very safe and effective treatment of BPPV which has the added advantage of being noninvasive procedure, with excellent results.

A New Coordinate System for Magnetic Resonance Imaging of the Vestibular System

Objectives: To develop and evaluate a new coordinate system for MRI of the vestibular system.

Methods: In this study, 53 internal auditory canal MRI and 78 temporal bone CT datasets were analyzed. Mimics Medical software version 21.0 was used to visualize and three-dimensionally reconstruct the image data. We established a new coordinate system, named W–X, based on the center of the bilateral eyeballs and vertex of the bilateral superior semicircular canals. Using the W–X coordinate system and Reid's coordinate system, we measured the orientations of the planes of the anterior semicircular canal (ASCC), the lateral semicircular canal (LSCC), and the posterior semicircular canal (PSCC).

Results: No significant differences between the angles measured using CT and MRI were found for any of the semicircular canal planes (p > 0.05). No statistical differences were found between the angles measured using Reid's coordinate system (CT) and the W–X coordinate system (MRI). The mean values of ∠ASCC & LSCC, ∠ASCC & PSCC, and ∠LSCC & PSCC were 84.67 ± 5.76, 94.21 ± 3.81, and 91.79 ± 5.22 degrees, respectively. The angle between the LSCC plane and the horizontal imaging plane was 15.64 ± 3.92 degrees, and the angle between the PSCC plane and the sagittal imaging plane was 48.79 ± 4.46 degrees.

Conclusion: A new W–X coordinate system was developed for MRI studies of the vestibular system and can be used to measure the orientations of the semicircular canals.

Nystagmus Parameters of Supine Roll Test Correlates With Prognosis After Repositioning Maneuver in Horizontal Semicircular Canal Benign Paroxysmal Positional Vertigo

Background: Positional nystagmus induced by supine roll test is characteristic for diagnosing horizontal semicircular canal benign paroxysmal positional vertigo (HC-BPPV). In this study, we aimed to explore the value of nystagmus parameters in by supine roll test (SRT) as prognostic factors in HC-BPPV.

Methods: We retrospectively analyzed the nystagmus parameters of 813 patients diagnosed with HC-BPPV by the SRT model in the SRM-IV system through video nystagmography. Then we used the computer-controlled canalith repositioning procedure (CCRP) mode for treatment. Based on the outcomes, patients were divided into either the cured group or the resistant group. The 1:1 propensity score matching (PSM) was applied to minimize potential selection bias. Then univariable and multivariable analyses were performed to identify the association of nystagmus parameters and the efficacy of CCRP.

Results: Among the 813 patients, 99 (12.2%) were classified in the resistant group. The right side of HC-BPPV patients was twice the number of the left side patients (537 vs. 276). PSM is used to pair resistant patients to the cured patients, in which 99 pairs were successfully matched. Results of univariate and multivariate analyses showed that patients in the resistant group have longer latency in the affected side [odds ratio (OR) = 1.231 (1.110–1.366); P < 0.001] and slower slow phase velocity (SPV) in the healthy side [OR = 0.957 (0.917–0.999); P = 0.045].

Conclusion: Nystagmus parameters may represent the characteristics of canalith. HC-BPPV patients with a longer latency in the affected side and slower SPV on the healthy side during SRT have a higher risk of HC-BPPV persisting after a single CCRP.

[Vertical downbeat nystagmus in benign paroxysmal positional vertigo]

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibulopathy. Ppatients with BPPV contact with otorhinolaryngologists in 25% of cases. Due to the polymorphism of this pathology, an urgent task is to asess differential diagnosis of BPPV with various variants of the central positional syndrome: vestibular migraine, myofascial cervical syndrome, organic changes in the structures of the cerebellum.

OBJECTIVE

To distinguish atypical forms of BPPV with downbeating vertical nystagmus and the central positional syndrome.

A possible objective test to detect benign paroxysmal positional vertigo. The role of the caloric and video-head impulse tests in the diagnosis

Background

Objectives

Methods

Results

Conclusion

Diagnostic and Therapeutic Maneuvers for Anterior Canal BPPV Canalithiasis: Three-Dimensional Simulations

Background and Objectives: Anterior canal BPPV is a rare BPPV variant. Various diagnostic and therapeutic maneuvers have been described for its management. The aim of this study was to use three-dimensional simulation models to visualize otoconial debris movement within the anterior canal during diagnostic tests and different liberatory maneuvers. This can help to optimize existing treatment maneuvers and help in the development of better management protocols. Methods: Based on reconstructed MRI images and fluid dynamics, a 3D dynamic simulation model (as a function of time) was developed and applied. Simulations of the supine head-hanging test for diagnosis of ac-BPPV were studied. Three repositioning maneuvers were simulated: 1) the Yacovino maneuver and its modifications, 2) the reverse Epley maneuver and 3) the short canal repositioning (CRP) maneuver. Results: The simulation showed that the supine head-hanging test is a good test for diagnosis of ac-BPPV affecting both labyrinths and demonstrated why there is no inversion of nystagmus on sitting up. The Yacovino maneuver was seen to be an effective treatment option for ac-BPPV without having to determine the side involved. However, simulations showed that the classical Yacovino maneuver carried a risk of canal switch to the posterior canal. To overcome this risk, a modified Yacovino maneuver is suggested. The reverse Epley maneuver was not an effective treatment. Short CRP is useful in ac-BPPV treatment; however, it requires determination of side of involvement. Conclusion: The 3D simulator of the movement of the otoconial debris presented here can be used to test the mechanism of action and the theoretical efficacy of existing diagnostic tests and maneuvers as well as to develop new treatment maneuvers to optimize BPPV treatment.

Agreement Between Physical Therapists in Diagnosing Benign Paroxysmal Positional Vertigo

BACKGROUND AND PURPOSE

Individuals with benign paroxysmal positional vertigo (BPPV) are frequently referred to physical therapy for management, but little is known on how reliable therapists are at diagnosing BPPV. The purpose of the study was to examine the agreement between physical therapists in identifying nystagmus and diagnosing BPPV.

METHODS

Thirty-eight individuals with complaints of positional vertigo, 19 from each of 2 clinics (clinics 1 and 2) that specialize in vestibular rehabilitation, had eye movements recorded using video goggles during positioning tests including supine-to-sit, supine roll, and Dix-Hallpike tests. Three therapists from each of the clinics independently observed videos, documented nystagmus characteristics of each testing position, and made a diagnosis for each case. Kappa (κ) statistics were calculated between therapists within each clinic for nystagmus identification and diagnosis.

RESULTS

Clinic 1 therapists demonstrated substantial to almost perfect agreement in identifying nystagmus during positional tests (κ = 0.68-1, P < 0.005). Clinic 2 therapists showed moderate to almost perfect agreement for presence of nystagmus (κ = 0.57-1, P < 0.005). Therapists at both sites had almost perfect agreement of diagnosis side, canal, and mechanism (κ = 0.81-1, P < 0.005).

DISCUSSION AND CONCLUSION

Therapists utilized observations from multiple positional tests to determine diagnoses. This was evident by occasional disagreement in nystagmus presence and characteristics, but agreement in diagnosis, including ruling out BPPV. The results may not be generalizable to all physical therapists or therapists' ability to diagnose central and atypical nystagmus presentations. Experienced physical therapists demonstrated strong agreement in diagnosing common forms of BPPV.Video Abstract available for more insight from the authors (see the Video Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A340).

Rare Disorders of the Vestibular Labyrinth: of Zebras, Chameleons and Wolves in Sheep's Clothing

The differential diagnosis of vertigo syndromes is a challenging issue, as many - and in particular - rare disorders of the vestibular labyrinth can hide behind the very common symptoms of "vertigo" and "dizziness". The following article presents an overview of those rare disorders of the balance organ that are of special interest for the otorhinolaryngologist dealing with vertigo disorders. For a better orientation, these disorders are categorized as acute (AVS), episodic (EVS) and chronic vestibular syndromes (CVS) according to their clinical presentation. The main focus lies on EVS sorted by their duration and the presence/absence of triggering factors (seconds, no triggers: vestibular paroxysmia, Tumarkin attacks; seconds, sound and pressure induced: "third window" syndromes; seconds to minutes, positional: rare variants and differential diagnoses of benign paroxysmal positional vertigo; hours to days, spontaneous: intralabyrinthine schwannomas, endolymphatic sac tumors, autoimmune disorders of the inner ear). Furthermore, rare causes of AVS (inferior vestibular neuritis, otolith organ specific dysfunction, vascular labyrinthine disorders, acute bilateral vestibulopathy) and CVS (chronic bilateral vestibulopathy) are covered. In each case, special emphasis is laid on the decisive diagnostic test for the identification of the rare disease and "red flags" for potentially dangerous disorders (e. g. labyrinthine infarction/hemorrhage). Thus, this chapter may serve as a clinical companion for the otorhinolaryngologist aiding in the efficient diagnosis and treatment of rare disorders of the vestibular labyrinth.

Update on benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo worldwide. This review considers recent advances in the diagnosis and management of BPPV including the use of web-based technology and artificial intelligence as well as the evidence supporting the use of vitamin D supplements for patients with BPPV and subnormal serum vitamin D.

A novel maneuver for diagnosis and treatment of torsional-vertical down beating positioning nystagmus: anterior canal and apogeotropic posterior canal BPPV

Introduction

In patients with benign paroxysmal positional vertigo, BPPV; a torsional-vertical down beating positioning nystagmus can be elicited in the supine straight head-hanging position test or in the Dix-Hallpike test to either side. This type of nystagmus can be explained by either an anterior canal BPPV or by an apogeotropic variant of the contralateral posterior canal BPPV Until now all the therapeutic maneuvers that have been proposed address only one possibility, and without first performing a clear differential diagnosis between them.

Objective

To propose a new maneuver for torsional-vertical down beating positioning nystagmus with a clear lateralization that takes into account both possible diagnoses (anterior canal-BPPV and posterior canal-BPPV).

Methods

A prospective cohort study was conducted on 157 consecutive patients with BPPV. The new maneuver was performed only in those with torsional-vertical down beating positioning nystagmus with clear lateralization.

Results

Twenty patients (12.7%) were diagnosed with a torsional-vertical down beating positioning nystagmus. The maneuver was performed in 10 (6.35%) patients, in whom the affected side was clearly determined. Seven (4.45%) patients were diagnosed with an anterior canal-BPPV and successfully treated. Two (1.25%) patients were diagnosed with a posterior canal-BPPV and successfully treated with an Epley maneuver after its conversion into a geotropic posterior BPPV.

Conclusion

This new maneuver was found to be effective in resolving all the cases of torsional-vertical down beating positioning nystagmus-BPPV caused by an anterior canal-BPPV, and in shifting in a controlled way the posterior canal-BPPV cases of the contralateral side into a geotropic-posterior-BPPV successfully treated during the followup visit. Moreover, this new maneuver helped in the differential diagnosis between anterior canal-BPPV and a contralateral posterior canal-BPPV.

Short Term Efficacy of Modified Epley’s Maneuvre Assisted by Visual Aid Dynamic Device Versus Unassisted Maneuvre for the Treatment of Posterior Canal BPPV

Introduction:

Modified Epley’s maneuver is the recommended treatment for the Posterior Canal (PC) BPPV. To enhance the efficacy of this maneuver, an easy to perform visual aid device (DizzyFIX) guided modified Epley’s maneuver was studied.

Material and Methods:

This prospective, double-blind, randomized study included consecutive patients with PC-BPPV based on clinical history, neuro-otological examination, and positive Dix- Hallpike (DHP) test from January 2018 to March 2019 at a neurology clinic of western India. Patients were randomly assigned treatment with either visual aid device assisted modified Epley’s maneuver, which constituted the case group or by a placebo device guided modified Epley’s maneuver, which constituted the control group. DizzyFIX was used as a visual aid device in the case group. Patients were followed up at one hour and 24 hours with DHP by the blinded examiners to observe for remission.

Results:

Out of 280 patients (140 patients in each group), 6 from the case, and 2 from the controls were lost from the follow-up. Overall, 134 cases were compared to 138 controls. The success rate of remission in the case and the control group at one-hour was 79.19% vs. 48.30%, respectively, with a p-value of 0.003. Similarly, the success rate in the case and control group at 24 hours was 95.27% vs. 80.62%, respectively, with a p-value of 0.011. At 1 hour, unadjusted Odd Ratio (OR) was 4.13, (C.I. 95% 2.02- 8.46) and at 24 hours, it was 4.37, (C.I. 95% 1.39-13.77), which was significant even after adjustment of co-variables (OR 4.02, C.I. 95% 2.34- 8.26) and (OR 4.11, C.I. 95% 2.30- 14.26), respectively.

Conclusion:

For short term treatment of PC-BPPV, DizzyFIX assisted modified Epley’s maneuver is more efficacious than unassisted modified Epley’s maneuver.

Short CRP for Anterior Canalithiasis: A New Maneuver Based on Simulation With a Biomechanical Model

Introduction/Objective: Anterior canalithiasis is an uncommon and challenging diagnosis. This is due in part to the difficulty of defining the affected side, the extreme positioning required to carry out described therapeutic maneuvers, and the infrequent use of specific maneuvers. Our objective is to present a new treatment alternative for anterior canalithiasis which is based on the well-known canalith repositioning procedure (CRP) described by Epley and which is used routinely in the treatment of both posterior and anterior canalithiasis. Analysis of the standard CRP for anterior canalithiasis with a biomechanical model validates that this new maneuver is an enhanced treatment option for anterior canalithiasis. We call the new maneuver the “short CRP.”

Methods: A previously published 3D biomechanical model of the human labyrinths for the study of BPPV was used to analyze the conventional CRP in the treatment of anterior canalithiasis. The expected position of free otoliths near the anterior ampulla of the anterior semicircular duct was followed while recreating the sequential positions of the CRP. Although the standard CRP was possibly effective, certain enhancements were evident that could increase successful repositioning. These enhancements were incorporated into the modification of the CRP presented here as the “short CRP” for anterior canalithiasis.

Results: The traditional CRP used for posterior canalithiasis can also be used for anterior canalithiasis. Although in the traditional CRP the head hangs 30° below horizontal, our simulation shows that a 40° head-hang below horizontal is an enhancement and may ensure progression of anterior otolith debris. Elimination of Position 4 of the classic CRP, in which the face is turned 45° toward the floor, was also seen as an enhancement as this position is predicted to cause retrograde movement of otoliths back into the anterior canal if the patient tucks the chin in position 4 or when sitting up.

Conclusion: A modification of the CRP called the “short CRP” can be used to treat anterior canalithiasis. Model analysis predicts possible increased efficacy over the standard CRP. Model analysis of existing BPPV treatments is a valuable exercise for examination and can lead to realistic enhancements in patient care.

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.

Benign Paroxysmal Positional Vertigo After Pediatric Sports-Related Concussion

OBJECTIVE

Report the clinical findings and outcomes among pediatric patients diagnosed with benign paroxysmal positional vertigo (BPPV) after sports-related concussion (SRC).

DESIGN

Retrospective case series.

SETTING

Multidisciplinary pediatric concussion program.

PATIENTS

Patients younger than 19 years with a sport or recreation activity-related concussion referred for comprehensive vestibular physiotherapy assessment.

MAIN OUTCOME MEASURE

Symptom resolution after targeted particle repositioning (PR).

RESULTS

During the study period, 115 pediatric SRC patients underwent vestibular physiotherapy assessment including 12 (10.4%) who were diagnosed with BPPV. Unilateral posterior semicircular canal (SCC) BPPV was diagnosed in 8/12 (75%) patients, and unilateral anterior SCC BPPV diagnosed in 4/12 (25%) patients. Benign paroxysmal positional vertigo was successfully treated in all patients with a mean of 1.58 targeted PR maneuvers (range = 1-4).

CONCLUSIONS

Comprehensive management of pediatric SRC requires a multidisciplinary approach to address the heterogeneous pathophysiology of persistent postconcussion symptoms. Pediatric SRC patients with coexisting BPPV should be considered for targeted PR.

Poor Treatment Outcomes Following Repositioning Maneuvers in Younger and Older Adults With Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review aimed to methodically review the available evidence on poor treatment outcomes after repositioning maneuver treatments in adults with BPPV and whether there are differences in the outcomes for older and younger adults.

DATA SOURCES

Embase, CINAHL, Scopus, PsycINFO (Ovid), Central Register of Controlled Trials (CENTRAL), and PubMed.

REVIEW METHODS

Studies were included if they were prospective experimental or observational studies with a minimal follow-up of 1 month; the subjects were at least 18 years old, had BPPV, and were treated with repositioning maneuvers. Studies were excluded if they were not available in English full text and if the outcomes used were confined to positional tests and subjective vertigo rating. Methodological quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklists. Meta-analysis was performed to compare outcomes for younger and older (≥60 years) subjects where multiple studies utilized similar outcomes.

RESULTS

Thirty-five studies were selected. The methodological quality was poor in more than 60% of the studies. Treatment efficacy, based on positional test results and symptom resolution and recurrence were the most common outcomes. Balance and quality of life measures improved after treatment but were not always normalized. Residual symptoms and psychoemotional consequences persisted in some subjects, despite BPPV resolution. Meta-analyses indicated poorer dynamic balance recovery and increased self-perceived level of handicap in the older group relative to the younger group.

CONCLUSIONS AND IMPLICATIONS

Although repositioning maneuvers were effective in BPPV management, some patients experienced residual dizziness, postural instability, recurrences, and psychoemotional consequences at least 1 month after repositioning. Moreover, older adults experienced less improvements in dynamic balance and self-perceived handicap rating compared with younger people. These issues may further impact on older adults with BPPV physically and mentally and should be addressed by future better-quality research and interventions.

Lateral Semicircular Canal BPPV…Are We Still Ignorant?

Benign Paroxysmal Vertigo is one of the most common causes of vertigo. The most common semicircular canal involved in pathogenesis of BPPV is Posterior semicircular canal. However anterior and lateral semicircular canals can also sometimes be responsible for BPPV but their involvement in pathogenesis is still underrated. The incidence of lateral semicircular canal BPPV is in literature is around 10-12% while anterior canal is about 3%. The main objective of this study was to provide the database for incidence of lateral canal BPPV from a tertiary care hospital with the aim that more clinicians incorporate this entity into their differential diagnosis when their cases of posterior canal BPPV are refractory. This was an observational cross-sectional study of 300 patients of BPPV who were coming in ENT OPD as primum or as referral. All the patients underwent both the Dix-Hallpike maneuver as well as the supine roll test. The patients who were having upbeating torsional vertical nystagmus on Dix-Hallpike were treated on lines of posterior canal BPPV whereas those with horizontal nystagmus on supine roll test were treated on lines of lateral canal BPPV. The data was tabulated and analysed for the incidence of lateral canal BPPV. Out of 300 patients; 188 were males and 122 were females. Most commonly affected age group by BPPV was 40-50 years. Out of 300 cases 260 cases (86.6%) had posterior BPPV and 37 cases (12.3%) had lateral canal BPPV. 3 cases (1%) also had anterior canal BPPV. 30/37 cases of lateral BPPV had geotropic nystagmus while 7 cases had apo-geotropic nystagmus. Posterior canal BPPv was treated by Epleys maneuver. Superior canal BPPV was treated by Yacovino maneuver. The cases of lateral canal BPPV were treated by either Vannucchi-asprella; Gufoni; Lempert maneuver or by the combination of two maneuvers. Lateral canal BPPV is an important diagnosis to consider in all cases of BPPV. Its true incidence is still under blanket as many clinicians are not using supine roll test routinely in their practice while diagnosing BPPV. Many refractory cases of BPPV can be cured if the involvement of other canals in its pathogenesis is kept in the mind so that correct diagnostic and repositioning maneuvers can be applied. We also encourage more institutional studies on lateral canal BPPV so that a standard treatment protocol with clear indications can be designed for this entity as is available for BPPV.

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.

Vertical Nystagmus in the Bow and Lean Test may Indicate Hidden Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo: Hypothesis of the Location of Otoconia

The ‘Bow and Lean Test’ (BLT) was developed for proper diagnosis of horizontal semicircular canal benign paroxysmal positional vertigo (HSC-BPPV). Occasionally, down- and/or up-beating vertical nystagmus is observed during the BLT. This study analyzed patients who exhibited vertical nystagmus in the BLT to comprehend the clinical significance of this sign. Of 2872 patients with vertigo between 2010 and 2015, 225 patients who showed vertical nystagmus in the BLT were enrolled. All patterns of vertical nystagmus were described based on their types of BPPV. After performing therapeutic maneuvers for BPPV, remnant symptoms in the BLT findings were investigated. Of the 225 patients with vertical nystagmus, 163 were posterior semicircular canal BPPV (PSC-BPPV). Down-beating in the bowing position and no nystagmus in the leaning position (‘Down/–’) was the most common type (190 of 225 patients). In addition, the nystagmus occurred in the form of ‘–/Up’, ‘Down/Up’, and ‘–/Down’. The pattern of vertical nystagmus may be related to the position of otoconia in the canals. The location of the otoconia enables the diagnosis of hidden PSC-BPPV. Even after treatment for BPPV, patients with vertical nystagmus in the BLT tended to complain remnant vertigo symptoms (44.8% vs. 23.9%, P = 0.022, in PSC-BPPV; 70.0% vs. 24.0%, P = 0.020, in HSC-BPPV). We thought that they actually had hidden PSC-BPPV and the otoconial debris may still in the PSC; this untreated PSC-BPPV might cause the remnant symptoms. In conclusion, vertical nystagmus in the BLT may indicate the presence of PSC-BPPV. Moreover, vertical nystagmus during the BLT may occur in patients with hidden PSC-BPPV who complain of remnant vertigo symptoms. Vertical nystagmus shown in the BLT may not include the possibility of central vertigo.

Can a Chronic BPPV With a History of Trauma be the Trigger of Symptoms in Vestibular Migraine, Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), and Whiplash Associated Disorders (WAD)? A Retrospective Cohort Study

BACKGROUND

In patients with chronic benign paroxysmal positional vertigo (BPPV), i.e., chronic vestibular multicanalicular canalithiasis (CVMCC), abnormal signals are transmitted from diseased labyrinths via the healthy vestibular nuclei complex to their end organs. The vestibulo-thalamo-cortical reflex as proposed in vestibular migraine is just one of these reflexes. In a group of patients diagnosed with CVMCC otolith repositioning maneuvers specific for each semicircular canal (SCC) ameliorated pain and other symptoms in 90%. Increased awareness of CVMCC may reduce suffering and continuous medication.

OBJECTIVE

To evaluate if CVMCC can be the trigger of symptoms in vestibular migraine, myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), and whiplash associated disorders (WAD).

STUDY DESIGN

Retrospective consecutive observational cohort study.

SETTING

Ambulatory at a private Otoneurology Centre.

PATIENTS

One hundred sixty-three patients with CVMCC and a history of trauma.

INTERVENTION

Based on the symptoms (structured symptom questionnaire), the patients are post hoc sub grouped according to the criteria of the different diagnoses.

MAIN OUTCOME MEASURE

Frequency of patients with CVMCC who fulfill the criteria of the different diagnoses.

RESULTS

98% of all patients with CVMCC fulfill the Barany Society criteria of a probable vestibular migraine; 17% fulfill the International Classification of Headache Disorders defined vestibular migraine criteria; 63% fulfill the Fukuda criteria of ME/CFS; 100% of the patients with WAD suffer from CVMCC.

CONCLUSION

This survey supports the hypothesis that CVMCC can be the trigger of symptoms in vestibular migraine, ME/CFS, and WAD. The actual diagnosis the patient receives is often in accordance with the patient's dominant symptom.

Questionnaire-based diagnosis of benign paroxysmal positional vertigo

OBJECTIVES

To develop a simple questionnaire for self-diagnosis of benign paroxysmal positional vertigo (BPPV).

METHODS

We developed a questionnaire that consisted of 6 questions, the first 3 to diagnose BPPV and the next 3 to determine the involved canal and type of BPPV. From 2016 to 2017, 578 patients with dizziness completed the questionnaire before the positional tests, a gold standard for diagnosis of BPPV, at the Dizziness Clinic of Seoul National University Bundang Hospital.

RESULTS

Of the 578 patients, 200 were screened to have BPPV and 378 were screened to have dizziness/vertigo due to disorders other than BPPV. Of the 200 patients with a questionnaire-based diagnosis of BPPV, 160 (80%) were confirmed to have BPPV with positional tests. Of the 378 patients with a questionnaire-based diagnosis of non-BPPV, 24 (6.3%) were found to have BPPV with positional tests. Thus, the sensitivity, specificity, and precision of the questionnaires for the diagnosis of BPPV were 87.0%, 89.8%, and 80.0% (121 of 161, 95% confidence interval 74.5%-85.5%). Of the 200 patients with a questionnaire-based diagnosis of BPPV, 30 failed to respond to the questions 4 through 6 to determine the involved canal and type of BPPV. The questionnaire and positional tests showed the same results for the subtype and affected side of BPPV in 121 patients (121 of 170, 71.2%).

CONCLUSION

The accuracy of questionnaire-based diagnosis of BPPV is acceptable.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that, in patients with dizziness, a questionnaire can diagnose BPPV with a sensitivity of 87.0% and a specificity of 89.8%.

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.

Management of Benign Paroxysmal Positional Vertigo in an Adult With Severe Osteogenesis Imperfecta

The purpose of this case report was to describe the evaluation and management of atypical benign paroxysmal positional vertigo (BPPV) in an adult with severe osteogenesis imperfecta. A 29-year-old male was referred to a physical therapist with extensive experience in vestibular rehabilitation who provided horizontal canal BPPV treatment with a canalith repositioning maneuver over two treatment sessions. The individual's symptoms had reduced by 65% and his nystagmus during the roll test was reduced. Extreme care is needed to safely reposition individuals living with severe osteogenesis imperfecta, but the repositioning can reduce symptoms and improve quality of life. Laryngoscope, 130:2241-2244, 2020.

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

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Benign Paroxysmal Positional Vertigo (BPPV) in Children and Adolescents: Clinical Features and Response to Therapy in 110 Pediatric Patients

OBJECTIVE

This study aimed to characterize the clinical features and outcomes of benign paroxysmal positional vertigo (BPPV) in the pediatric population.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary care center.

PATIENTS

One hundred ten patients, aged 5 to 19 years old, diagnosed with BPPV.

MAIN OUTCOME MEASURES

Patient demographics, comorbidities, canal involvement, response to treatment, and incidence of recurrence.

RESULTS

BPPV was diagnosed in 19.8% of patients seen for dizziness during the study period. Patient age ranged 5 to 19 years old (mean =13.4 ± 3.4 yr). Female:male ratio was 3:2. The most prevalent comorbidities were concussion (n = 42, 38.2%) and migraine disorders (n = 33, 30.0%). Average time to diagnosis from symptom onset was 178.2 ± 190.8 days. The posterior canal was most frequently affected (n = 80, 72.7%), followed by the lateral canal (n = 37, 33.6%) and superior canal (n = 21, 19.1%), and 36.4% (n = 40) of patients had multiple canals affected. Treatment requiring more than or equal to five maneuvers to achieve resolution was observed in 11.8% of cases (n = 13). Recurrence was observed in 18.2% of cases. A logistic regression analysis demonstrated that patients with vestibular migraine or benign paroxysmal vertigo of childhood had five times higher odds of recurrence of BPPV, p = 0.003, 95% [1.735, 15.342], than those who did not have either.

CONCLUSIONS

BPPV is a relatively common cause of dizziness in the pediatric population. Children and adolescents with BPPV can be successfully treated with repositioning maneuvers but may be at risk for treatment resistance and recurrence. Increased awareness of BPPV in pediatric patients may reduce delays in identification and treatment.

The Role of Physical Therapy in Concussion Rehabilitation

A complex diagnosis such as concussion requires a multidisciplinary patient-centered approach to maximize health outcomes. There is growing evidence to support the role of the Physical Therapist as a key member of the team of healthcare professionals managing children and adolescents with a protracted recovery following concussion. Symptoms such as headache, dizziness, neck pain, gaze instability, balance dysfunction, and fatigue can be addressed through a multimodel approach. This article provides an overview of the targeted pathways of examination and treatment of individuals with a concussion through vestibular rehabilitation, cervicogenic rehabilitation, exertional training, and patient education.

Diagnosis strategy and Yacovino maneuver for anterior canal-benign paroxysmal positional vertigo

OBJECTIVE

To investigate the diagnosis strategy of anterior canal-benign paroxysmal positional vertigo (AC-BPPV) and the therapeutic effects of the Yacovino maneuver.

METHODS

The clinical data of 40 AC-BPPV patients were collected. The nystagmus characteristics induced by the Dix-Hallpike (D-H) and straight head-hanging (SHH) tests, the diagnostic methods used, and the effectiveness of the Yacovino maneuver for the treatment of AC-BPPV were all retrospectively analyzed.

RESULTS

Among the 40 cases analyzed, 19 patients had simple AC-BPPV, 11 patients had AC-posterior canal BPPV, and 10 patients had AC-horizontal canal BPPV. D-H and SHH tests showed down-beating nystagmus in 26 and 33 patients, respectively, and showed down-beating and torsional nystagmus in 14 and 7 patients, respectively. AC-BPPV was diagnosed in 15 patients based on the presence of typical BPPV in other canals, in 9 patients based on typical disease history and the results of position tests, in 6 patients based on effectiveness of the treatment with the Yacovino maneuver, in 4 patients based on the treatment effectiveness and the presence of typical BPPV in other canals, in 3 patients based on the treatment effectiveness and the follow-up outcome, in 2 patients based on the typical BPPV in other canals and occurrence of canal conversion, and in 1 patient based on the treatment effectiveness and occurrence of canal conversion. Thirteen patients with canalolithiasis and four patients with cupulolithiasis were cured after the initial Yacovino maneuver treatment. Twenty-one patients with canalolithiasis and seven patients with cupulolithiasis were cured following 1 week of treatment.

CONCLUSIONS

The effectiveness of the Yacovino maneuver, the follow-up outcome, the presence of typical BPPV in other canals, and the occurrence of canal conversions contribute to AC-BPPV diagnosis. The Yacovino maneuver was found to be more effective in AC-BPPV patients with canalolithiasis than in those with cupulolithiasis.

Benign positional vertigo, its diagnosis, treatment and mimics

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

Benign paroxysmal positional vertigo

Objectives

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular end‐organ disease. This article aims to summarize research findings and key discoveries of BPPV. The pathophysiology, diagnosis, nonsurgical, and surgical management are discussed.

Methods

A comprehensive review of the literature regarding BPPV up through June 2018 was performed.

Results

BPPV is typified by sudden, brief episodes of vertigo precipitated by specific head movements. While often self‐limited, BPPV can have a considerable impact on quality of life. The diagnosis can be established with a Dix‐Hallpike maneuver for the posterior and anterior canals, or supine roll test for the horizontal canal, and typically does not require additional ancillary testing. Understanding the pathophysiology of both canalithiasis and cupulolithiasis has allowed for the development of various repositioning techniques. Of these, the particle repositioning maneuver is an effective way to treat posterior canal BPPV, the most common variant. Options for operative intervention are available for intractable cases or patients with severe and frequent recurrences.

Conclusions

A diagnosis of BPPV can be made through clinical history along with diagnostic maneuvers. BPPV is generally amenable to in‐office repositioning techniques. For a small subset of patients with intractable BPPV, canal occlusion can be considered.

Level of Evidence

N/A

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.