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

Gufoni maneuver for treatment of horizontal canal benign paroxysmal positional vertigo: a systematic review of randomized controlled trials

PURPOSE

This review aims to investigate the effects of the Gufoni maneuver on horizontal semicircular canal benign paroxysmal positional vertigo (HC-BPPV).

METHODS

A comprehensive search, including PubMed, PEDro, REHABDATA, SCOPUS, EMBASE, and Web of Science, was conducted to determine randomized clinical trials (RCTs) studying the effects of the Gufoni maneuver for HC-BPPV from inception to March 1, 2024. The quality of the included studies was estimated using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Ten randomized controlled trials (RCTs) were included in this review with a total of 1025 HC-BPPV patients (mean age = 58.58 years; 63% female; 55% right-side HC-HBPPV; 49% geotropic HC-BPPV). The included RCTs ranged from 4 to 9 out of 10 (median = 6.5) on the PEDro scale. The included studies showed that the Gufoni maneuver revealed efficacy when compared to the sham maneuver but not when compared to other maneuvers such as the Barbecue roll maneuver, the Appiani maneuver, the Mastoid oscillation, the head shaking, and the modified Gufoni maneuver.

CONCLUSIONS

The Gufoni maneuver is considered an option for treating patients with geotropic or apogeotropic HC-BPPV. Precise diagnosis of the BPPV, the subtype of HC-BPPV, symptom duration, history of previous BPPV attacks, the applied methods of maneuver and the proficiency of the clinician performing the maneuver, proper diagnosis, presence of any underlying health conditions are critical for successful treatment. Further studies are strongly warranted.

Multimodal deep learning-based diagnostic model for BPPV

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is a prevalent form of vertigo that necessitates a skilled physician to diagnose by observing the nystagmus and vertigo resulting from specific changes in the patient's position. In this study, we aim to explore the integration of eye movement video and position information for BPPV diagnosis and apply artificial intelligence (AI) methods to improve the accuracy of BPPV diagnosis.

METHODS

We collected eye movement video and diagnostic data from 518 patients with BPPV who visited the hospital for examination from January to March 2021 and developed a BPPV dataset. Based on the characteristics of the dataset, we propose a multimodal deep learning diagnostic model, which combines a video understanding model, self-encoder, and cross-attention mechanism structure.

RESULT

Our validation test on the test set showed that the average accuracy of the model reached 81.7%, demonstrating the effectiveness of the proposed multimodal deep learning method for BPPV diagnosis. Furthermore, our study highlights the significance of combining head position information and eye movement information in BPPV diagnosis. We also found that postural and eye movement information plays a critical role in the diagnosis of BPPV, as demonstrated by exploring the necessity of postural information for the diagnostic model and the contribution of cross-attention mechanisms to the fusion of postural and oculomotor information. Our results underscore the potential of AI-based methods for improving the accuracy of BPPV diagnosis and the importance of considering both postural and oculomotor information in BPPV diagnosis.

Benign paroxysmal positional vertigo and asymmetric hearing loss: is the worst hearing ear likely to suffer from otoconial displacement?

PURPOSE

Benign paroxysmal positional vertigo (BPPV) may be found in patients complaining of hearing disorders. The aim of our investigation was to describe audiological findings in BPPV patients, focusing on subjects with asymmetric hearing loss (AHL), to better understand whether otoconial displacement may occur preferentially in the worst hearing ear.

METHODS

A prospective study was performed on 112 BPPV patients. We divided the sample into subjects who suffered from AHL (G1) and patients with did not (G2). Data regarding vestibular symptoms, tinnitus, migraine, antivertigo drug therapy, and vascular risk factors were collected.

RESULTS

Out of 30 AHL subjects, 83.33% of them were affected by sensorineural hearing loss (SNHL) in at least one ear, with a significant difference in the distribution of hearing loss type between groups (p = 0.0006). In 70% of cases, the ear affected by BPPV was the one with the worst hearing threshold (p = 0.02); threshold asymmetry predicted BPPV in the worst hearing ear (p = 0.03). The predictability depended neither on the hearing threshold gap between ears nor the severity of the hearing threshold in the worst ear (p > 0.05). No differences in vascular risk factors between groups were observed (p > 0.05). We evidenced a moderate correlation between age and hearing threshold (ρ = 0.43). Age did not result a predictive factor for residual dizziness or BPPV in the worst ear (p > 0.05).

CONCLUSIONS

Our study supports the likelihood of an otoconial displacement in the worse hearing ear in BPPV patients. Clinicians should start testing the worst hearing ear when managing AHL patients with suspected BPPV.

Evaluation of the reliability and validity of the upright head roll test for lateral semicircular canal benign paroxysmal positional vertigo

BACKGROUND

The upright head roll test (UHRT) is a recently introduced diagnostic maneuver for lateral semicircular canal benign paroxysmal positional vertigo (LSC-BPPV).

OBJECTIVE

This study aimed to evaluate the reliability and validity of the UHRT.

METHODS

Two separate studies were conducted. Study 1 analyzed 827 results of videonystagmography (VNG) to assess UHRT reliability, and Study 2 analyzed 130 LSC-BPPV cases to evaluate UHRT validity.

RESULTS

The inter-test reliability between UHRT and the supine head roll test (SHRT) showed substantial agreement (Cohen's kappa = 0.753) in direction-changing positional nystagmus (DCPN) and almost perfect agreement (Cohen's kappa = 0.836) in distinguishing the direction of DCPN. The validity assessment of UHRT showed high accuracy in diagnosing LSC-BPPV (80.0%) and in differentiating the variant types (74.6%). UHRT was highly accurate in diagnosing the canalolithiasis type in LSC-BPPV patients (Cohen's kappa = 0.835); however, it showed only moderate accuracy in diagnosing the cupulolithiasis type (Cohen's kappa = 0.415). The intensity of nystagmus in UHRT was relatively weaker than that in SHRT (P < 0.05).

CONCLUSION

UHRT is a reliable test for diagnosing LSC-BPPV and distinguishing subtypes. However, UHRT has a limitation in discriminating the affected side owing to a weaker intensity of nystagmus than SHRT.

Efficacy of the Head Rotation Test With Bowing for the Lateral Canal Benign Paroxysmal Positional vertigo

OBJECTIVES

To evaluate the efficacy of the head rotation test with bowing (B-HRT) in the sitting position in diagnosing lateral semicircular canal benign paroxysmal positional vertigo (LSC-BPPV).

METHODS

The efficacy outcomes of lateralization of 25 patients with LSC-BPPV were prospectively evaluated using B-HRT. Traditional head toration in the supine position (S-HRT) and the bow and lean test were also assessed for comparative effectiveness.

RESULTS

Direction-changing nystagmus was detected in all patients with LSC-BPPV (100%) using B-HRT. The nystagmus direction (geotropic or apogeotropic) determined by B-HRT was consistent with that determined by S-HRT with a perfect level of agreement (Cohen κ = 1.0, p < 0.001**). In 76.0% of the cases, the determination of the affected ear was concordant between B-HRT and S-HRT (Cohen κ = 0.409, p = 0.037*). The concordance rate between B-HRT and bow and lean test showed a fair level of agreement (68.0%; Cohen κ = 0.286, p = 0.126) with no statistical significance. On comparing the peak slow-phase velocity (SPV), SPVs of positional nystagmus on the stronger side and weaker side did not differ statistically significantly between S-HRT and B-HRT. In 12 of the 25 cases, in which the peak SPV asymmetry was determined as less than 30% by S-HRT (average, 11.00 ± 6.87%), the asymmetry determined by B-HRT (average, 47.31 ± 34.78%) was significantly higher, facilitating lesion identification by performing B-HRT together ( p = 0.001*).

CONCLUSION

B-HRT in the sitting position identified direction-changing nystagmus in LSC-BPPV. B-HRT is helpful in facilitating the diagnosis of LSC-BPPV in the sitting position and determination of the affected ears in cases with nonprominent differences in bilateral nystagmus intensity according to S-HRT.

Spontaneous Nystagmus in Patients With Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo

OBJECTIVE

This study aimed to investigate the incidence of spontaneous nystagmus (SN) in posterior semicircular canal (PSCC) benign paroxysmal positional vertigo (BPPV) and its effect on treatment outcomes.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary referral center.

METHODS

This study included 50 patients with idiopathic unilateral PSCC BPPV between July 2021 and May 2022. The presence of SN was investigated, and the results of the bithermal caloric test and video head impulse test (vHIT) were compared.

RESULTS

SN was observed in 13 (26%) of the 50 patients presenting PSCC BPPV. The direction of SN was mainly unidirectional and horizontal in 12 of the 13 patients with a slow-phase velocity ranging from 2 to 4°/s. One patient presented an upbeating torsional SN at the initial evaluation. The mean vHIT gain of the PSCC on the affected side was significantly lower in patients with SN than those without SN (p = .004, Mann-Whitney U test). The proportion of patients who recovered within 2 sessions of the repositioning maneuver was significantly higher in those without SN than that in those with SN (p < .001, Fisher's exact test).

CONCLUSION

This study demonstrated that the treatment outcomes of PSCC BPPV were significantly worse in patients with SN than those without SN. Examining the presence of SN in patients with PSCC BPPV may be helpful in counseling the patients on prognosis, and it is expected that more sessions of canalith repositioning maneuver may be required to treat PSCC BPPV in patients with SN than those without SN.

Prevention of Recurrent Benign Paroxysmal Positional Vertigo: The Role of Combined Supplementation with Vitamin D and Antioxidants

Benign paroxysmal positional vertigo (BPPV) usually has a favorable course, although it is possible to observe BPPV with a high recurrence rate. Previous studies suggested that vitamin D deficiency might affect BPPV recurrences, and oxidative stress might play a complementary role in BPPV pathogenesis. This multicentric trial aimed to evaluate the effectiveness of oral nutritional supplementation with a compound of alpha-lipoic acid, Carnosine, and Zinc (LICA® (Difass International, Coriano (RN), Italy)), vitamins of group B and vitamin D in preventing BPPV recurrences. A total of 128 patients with high recurrence-BPPV were randomized in three arms: Arm 1 consisted of subjects with “insufficient” or “deficient” vitamin D blood levels, treated with daily oral supplementation of LICA®, vitamins of group B and vitamin D3 (800 UI), Arm 2 included BPPV subjects with “sufficient” vitamin D who did not receive any nutritional support, and Arm 3 included subjects with a “sufficient” serum concentration of vitamin D who received supplementation with a compound of LICA® and Curcumin. After six months of follow-up, a significant reduction of BPPV relapses compared to the baseline was found only in Arm 1 (−2.32, 95% CI: 3.41−1.62, p-value < 0.0001). Study results suggested that oral nutritional supplementation with vitamin D3 plus antioxidants can prevent relapses in patients suffering from high recurrence-BPPV.

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.

Modified Interpretations of the Supine Roll Test in Horizontal Canal BPPV Based on Simulations: How the Initial Position of the Debris in the Canal and the Sequence of Testing Affects the Direction of the Nystagmus and the Diagnosis

Background and Objectives

The aim of this study was to show with three-dimensional simulations how the diagnostic supine roll test (SRT) is affected by the initial position of the debris within the horizontal canal (hc) and study the nystagmus patterns on changing the sequence of testing and its impact on the diagnosis of the side of involvement in hc-BPPV.

Methods

A 3D dynamic simulation model was developed and applied based on reconstructed MRI images and fluid dynamics. Each semicircular canal was linked to the respective extraocular muscles to visualize nystagmus generated on stimulation of the canal.

Results

The simulations of hc-canalithiasis showed that the nystagmus pattern seen with the SRT is changed by the initial position of the otolith debris within the canal and the sequence of testing. The debris changes position during SRT so that sequential steps do not start at the initial position as previously assumed. The sequence of performing the SRT steps from the right or left side influences the nystagmus pattern generated: bilateral direction-changing, bilateral direction-fixed, and unilateral nystagmus can be seen in different test conditions. The SRT itself may even reposition the debris out of the canal.

Conclusions and Clinical Implications

Simulations provide a dynamic tool to study the diagnostic SRT in hc-canalithiasis. Starting the SRT from right or left has a major impact on the test outcome (unlike the Dix-Hallpike maneuver). The findings provide a new interpretation for the results of the SRT. The simulations explain the phenomenon of direction-fixed nystagmus as a logical consequence of starting the SRT with the head turned toward the non-affected side in hc-canalithiasis with debris in the ampullary arm. They also show that unilateral nystagmus seen on SRT indicates canalithiasis of the non-ampullary arm of the side opposite to the side of nystagmus. The generation of bilateral direction-changing, bilateral direction-fixed, and unilateral nystagmus can be the cause of misdiagnoses in terms of the affected side and underlying mechanisms. Finally, a recommendation for a standardized protocol for the sequence of positional tests should be established to ensure uniform interpretation of test results.

Recovery of Regular Daily Physical Activities Prevents Residual Dizziness after Canalith Repositioning Procedures

OBJECTIVE

Residual dizziness is a disorder of unknown pathophysiology, which may occur after repositioning procedures for benign paroxysmal positional vertigo. This study evaluates the relationship between regular daily physical activity and the development of residual dizziness after treatment for benign paroxysmal positional vertigo.

STUDY DESIGN

Prospective observational cohort study.

SETTING

Academic university hospital.

METHODS

Seventy-one patients admitted with benign paroxysmal positional vertigo involving the posterior semicircular canal were managed with Epley's procedure. Three days after successful treatment, the patients underwent a telephone interview to investigate vertigo relapse. If the patients no longer complained of vertigo, they were asked about symptoms consistent with residual dizziness. Subsequently, they were asked about the recovery of physical activities they regularly performed prior to the onset of vertigo.

RESULTS

Sixty-nine patients (age: 57.79 ± 15.05) were enrolled: five (7.24%) reported vertigo relapse whereas twenty-one of sixty-four non-relapsed patients (32.81%) reported residual dizziness. A significant difference in the incidence of residual dizziness was observed considering the patients' age (p = 0.0003). Of the non-relapsed patients, 46 (71.88%) recovered their regular dynamic daily activities after treatment and 9 (19.57%) reported residual dizziness, while 12 of the 18 patients (66.67%) who did not resume daily activity reported residual symptoms (p = 0.0003). A logistic regression analysis showed a significant association between daily activity resumption and lack of residual dizziness (OR: 14.01, 95% CI limits 3.14-62.47; p = 0.001).

CONCLUSIONS

Regardless of age, the resumption of regular daily physical activities is associated with a lack of residual dizziness.

Case Report: Bow Hunter Syndrome—One Reason to Add Non-gravity Dependent Positional Nystagmus Testing to Your Clinical Neuro-Otologic Exam

This case study describes transient downbeat nystagmus with vertigo due to a bilateral Bow Hunters Syndrome that was initially treated for 7 months as a peripheral benign paroxysmal positional vertigo. Normal static angiography and imaging studies (magnetic resonance, computed tomography) contributed to the mis-diagnosis. However, not until positional testing with the patient in upright (non-gravity dependent) was a transient downbeat nystagmus revealed with vertigo. The patient was referred for neurosurgical consult. Unfortunately, surgery was delayed due to suicidal ideation and hospitalization. Eventually, vertigo symptoms resolved following a C4-5 anterior cervical dissection and fusion. This case highlights the critical inclusion of non-gravity dependent position testing as an augment to the positional testing component of the clinical examination as well as the extreme duress that prolonged positional vertigo can cause.

Spontaneous Jamming of Horizontal Semicircular Canal Combined with Canalolithiasis of Contralateral Posterior Semicircular Canal

Spontaneous canalith jam is an uncommon form of benign paroxysmal positional vertigo mimicking acute vestibular neuritis. We described for the first time a spontaneous horizontal semicircular canalith jam associated with a typical canalolithiasis involving contralateral posterior semicircular canal (PSC), illustrating how the latter condition modified direction-fixed nystagmus during head movements. An 81-year-old woman with persistent vertigo referred to our center. Video-Frenzel examination showed horizontal direction-fixed right-beating nystagmus in primary gaze position, inhibited by visual fixation. She exhibited corrective saccades after leftward head impulses. Chin-to-chest positioning at the head-pitch test did not modify spontaneous nystagmus, whereas slight torsional components with the top pole of the eye beating toward the right ear appeared in backward head-bending, resulting in mixed horizontal-torsional nystagmus. At supine positioning tests, direction-fixed nystagmus turned into direction-changing geotropic horizontal nystagmus, which was stronger on the left side, while overlapping upbeat nystagmus with torsional right-beating components appeared on the right. Primary clinical findings were consistent with a left horizontal semicircular canalith jam, inducing a persistent utriculofugal cupular displacement, combined with a typical right-sided PSC-canalolithiasis. Once canalith jam crumbled, resulting in a non-ampullary arm canalolithiasis of the horizontal semicircular canal, both involved canals were freed by debris with appropriate repositioning procedures.

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

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

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

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

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