Climatic variations and benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo(BPPV) is probably the most common diagnosis at vertigo clinics.Seasonal cycles of several human illnesses could be attributed variously to changes in atmospheric or weather conditions.In this retrospective study,patients with BPPV from January 2010 to December 2012 were studied,and their charts were reviewed.Statistical analysis revealed a statistically significant difference in patients’ numbers among different months of the year.Also there is a significant statistical correlation between the numbers of patients with climatic variations especially the temperature.The present paper discusses the possible explanations for these results which confirms the seasonal variations in BPPV,together with a review of literature to view the possible associations with other disorders that causes such seasonality.

Causes and treatment of idiopathic benign paroxysmal positional vertigo based on endocrinological and other metabolic factors

The genesis of the Benign Paroxysmal Positional Vertigo(BPPV)seems to be related to some metabolic factors.These factors,such as vitamin D,glucocorticoids,and even thyroid and growth hormones,can affect bone metabolism and the mineralization of otoconia.It also seems to link to factors related to aging or nutritional habits.Besides,since the incidence of BPPV is quantitatively higher in women than in men,female sex steroids could be associated with this process.It could be useful to understand how these factors act in otoconial mineralization if we want to develop treatments aimed at preventing or delaying BPPV recurrences.In this review,we will analyze the role of these metabolic and hormonal factors in otoconial mineralization and in the treatment of BPPV.

BENIGN PAROXYSMAL POSITIONAL VERTIGO

One of the most common causes of vertigo is Benign Paroxysmal Positional Vertigo(BPPV),a sensation of spinning that is caused by a sudden change in head position.This type of vertigo was first described by Robert Barany in the early 1920s[1].He suggested that BPPV was caused by abnormal otoliths,also called statoconium or otoconius,a structure in the saccule or utricle in

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

Background:Benign paroxysmal positional vertigo(BPPV)is characterized by vertigo lasting from seconds to minutes,induced by head movements.Objectives:Our study aimed to investigate the clinical significance of the caloric vestibular and video head-impulse tests(vHIT)diagnosing the disorder.Methods:68 patients suffering from posterior canal BPPV(25 male,43 females,mean age±SD,54.5±13.2 years)and 56 patients with a normal functioning vestibular system as control were investigated.Bithermal caloric test and vHIT was performed during the same medical check-up.Canal paresis(CP%),gain(GA)and asymmetry(GA%)parameters were calculated.Results:The Dix-Hallpike manoeuvre was only positive in 4%of this population.The CP%parameter was only pathologic in two patients,and there was no significant difference between control and BPPV patients(p=0.76).The GA value was never under 0.8 in this population,but GA%was abnormal in 63.2%.A significant difference comparing the GA%values to the control group was seen(p=0.034).There was no correlation detected between the CP%and GA%values in BPPV.Regarding the GA%value,61%sensitivity and 76%specificity was seen.Conclusion:The Dix-Hallpike manoeuvre was not often positive in the non-acute phase of BPPV;therefore,objective testing is essential.The caloric test does not have clinical significance in BPPV,but vHIT can be helpful based on the GA%parameter。

A comparative study of two methods for treatment of benign paroxysmal positional vertigo in the emergency department

Introduction: Posterior canal benign paroxysmal positional vertigo (PC-BPPV) is considered the mostcommon cause of peripheral vertigo in the emergency department (ED). Although the canalith repositioning maneuver (CRM) is the standard of care, the most effective method to deliver it in the ED hasbeen poorly studied.Objective: To compare two protocols of the Epley maneuver for the treatment of PC-BPPV.Patients and methods: We prospectively recruited 101 patients with unilateral PC-BPPV on physical examination, randomizing them to either a single Epley maneuver (EM) (n ¼ 46) or multiple maneuvers(n ¼ 55) on the same visit. Measured outcomes included presence/absence of positional nystagmus,resolution of vertigo, and score on the dizziness handicap inventory (DHI) at follow-up evaluations. TheDHI was stratified into mild ( 30) and moderate-severe (>30).Results: Normalization of the Dix-Hallpike maneuver at day 5 was observed in 38% of the single EMgroup and 44.4% in the multiple EM group (p ¼ 0.62). The DHI showed reduction from 42.2 (SD 18.4) to31.9 (SD 23.7) in the single EM group and from 43.7 (SD 22.9) to 33.5 (SD 21.5) in the multiple EM group(p ¼ 0.06). A higher number of patients improved from moderate-severe to mild DHI (p ¼ 0.03) in thesingle EM group compared to the multi-EM group (p ¼ 0.23).Conclusion: There was no statistically significant difference between performing a single EM versusmultiple EMs for treatment of PC-BPPV in the emergency department. The single EM approach isassociated with shorter physical contact between patients and examiner, which is logically safer in apandemic context.

Role of subjective visual vertical in patients with posterior canal benign paroxysmal positional vertigo as a prognostic marker after canalith repositioning maneuver

Objective:To study the potential role of subjective visual vertical(SVV)as a prognostic marker for canalith repositioning maneuver(CRM)in patients with posterior canal benign paroxysmal positional vertigo(PC-BPPV)for the Indian population.Methods:SVV was examined in 30 patients with PC-BPPV before and after canalith repositioning maneuver and after complete resolution of PC-BPPV.Study parameters included the mean of 10 angular tilt readings and direction of deviation,which were compared before and after CRM and following complete resolution of PC-BPPV.Results:The angle of SVV tilt was greater and deviated towards the affected ear before CRM in all patients,which decreased significantly shortly after CRM and continued to decrease after complete resolution of PC-BPPV(p<0.0001).Conclusions:SVV can be used to test utricular dysfunction in PC-BPPV.The angle of tilt improves in response to CRM,which may be used as a prognostic marker in patients with PC-BPPV receiving CRM.

Benign paroxysmal positional vertigo with congenital nystagmus: A case report

BACKGROUND Benign paroxysmal positional vertigo(BPPV)is a form of temporary vertigo induced by moving the head to a specific position.It is a self-limited,peripheral,vestibular disease and can be divided into primary and secondary forms.Congenital nystagmus(CN),an involuntary,rhythmic,binocular-symmetry,conjugated eye movement,is found at birth or within 3 mo of birth.According to the pathogenesis,CN can be divided into sensory-defect nystagmus and motordefect nystagmus.The coexistence of BPPV and CN is rarely seen in the clinic.CASE SUMMARY A 62-year-old woman presented to our clinic complaining of a 15-d history of recurrent positional vertigo.The vertigo lasting less than 1 min occurred when she turned over,sometimes accompanied by nausea and vomiting.Both the patient and her father had CN.Her spontaneous nystagmus was horizontal to right;however,the gaze test revealed variable horizontal nystagmus with the same degree when the eyes moved.The patient’s Dix-Hallpike test was normal,except for persistent nystagmus,and the roll test showed severe variable horizontal nystagmus,which lasted for about 20 s in the same direction as her head movement to the right and left,although the right-side nystagmus was stronger than the left-side.Since these symptoms were accompanied by nausea,she was diagnosed with BPPV with CN and treated by manual reduction.CONCLUSION Though rare,if BPPV with CN is correctly identified and diagnosed,reduction treatment is comparably effective to other vertigo types.

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

Objective:We aimed to describe the clinical features of the apogeotropic variant of horizontal canal benign paroxysmal positional vertigo(HC BPPV-AG)in a cluster of patients with restrictive neck movement disorders and a new therapeutic manoeuvre for its management.Methods:In a retrospective review of cases from an ambulatory tertiary referral center,patients with HC BPPV-AG in combination with neck movement restriction that prevented any classical manual repositioning procedure or who were refractory to canalith repositioning manoeuvres,were treated with a new manoeuvre comprised of sequential square-wave pattern of head and body supine rotations while nystagmus was being monitored,until either an apogeotropic to geotropic conversion or resolution of the nystagmus was observed.Results:Fifteen patients were studied.All but one[14/15 cases]showed a positive therapeutic response to the repositioning procedure in a single session.In two cases,a direct relief of vertigo and elimination of nystagmus was observed without an intermediate geotropic phase.Although in three patients the affected ear was not initially identified,it was ultimately identified and successfully treated by the square wave manoeuvre in all of them.Conclusions:The square-wave manoeuvre is an alternative for HC BPPV-AG treatment in either cases with neck restriction,where the affected side is not well identified at the bedside or when other manoeuvres fail to resolve the HC BPPV-AG.

CASE REPORT: TOTAL SUDDEN HEARING LOSS WITH BENIGN PAROXYSMAL POSITIONAL VERTIGO

Introduction Sudden sensorineural hearing loss(SSNHL)is defined as a hearing loss of at least 30 dB over three contiguous frequencies occurring in less than 3 days[1].Vertigo and profound hearing loss are considered poor prognostic factors in SSNHL[2-4].The most common diseases associated with vertigo in SSNHL include BPPV,vestibular neu-[3]

Clinical observation on ginger-partitioned moxibustion plus manual repositioning for benign paroxysmal positional vertigo(BPPV)

Objective： To investigate the clinical effect of ginger-partitioned moxibustion combined with manual repositioning for benign paroxysmal positional vertigo（BPPV）. Methods： A total of 76 BPPV cases were randomly allocated into an observation group（n=38） and a control group（n=38）. Patients in the observation group received ginger-partitioned moxibustion at Tinggong（SI 19） plus manual repositioning, whereas patients in the control group received the same manual repositioning alone. Results： After 48 h of treatment, the total effective rate was 94.7% in the observation group, versus 86.8% in the control group; after 7 d of treatment, the total effective rate was 78.9% in the observation group, versus 73.7% in the control group, both showing between-group statistical differences（P〈0.05）. The follow-up after 3 months showed that 2 cases（6.7%） got relapse in the observation group, versus 8 cases（28.6%） in the control group, showing a statistical difference（P〈0.05）. The adverse reaction rate was 2.6% in the observation group, versus 21.1% in the control group, showing a statistical difference（P〈0.05）. Conclusion： Ginger-partitioned moxibustion at Tinggong（SI 19） plus manual repositioning can obtain better effect for BPPV than manual repositioning alone. In addition, this therapy has stable efficacy and causes less adverse reactions.

A 3D benign paroxysmal positional vertigo model for study of otolith disease

Objective:To develop a three-dimensional study tool of the membranous labyrinth in order to study the pathophysiology, diagnostic workup and treatment of benign paroxysmal posi-tional vertigo (BPPV). BPPV is the most common cause of peripheral vertigo. Its diagnosis and treat-ment depend on an understanding of the anatomy of the vestibular labyrinth and its position relative to the head. To date, many illustrations have been made to explain principals of diagnosis and treat-ment of BPPV, but few have been based on anatomical studies of the membranous labyrinth. Methods:A cadaveric human membranous labyrinth was axially sectioned at 20 mm resolution, stained and segmented to create a high-resolution digital model. The model was cloned to create an enantio-meric pair of labyrinths. These were associated a 3D model of a human skull, segmented from MRI data, and were oriented according to established anatomic norms. Canal markers representing otoliths were created to mark canalith position during movement of the model within the 3D environment. Results:The model allows visualization of true membranous labyrinth anatomy in both ears simulta-neously. The dependent portion of each semicircular duct and of the utricle can easily be visualized in any head position. Moveable markers can mark the expected progress of otolith debris with changes in head position and images can be captured to document simulations. The model can be used to simulate pathology as well as diagnostic maneuvers and treatment procedures used for BPPV. The model has great potential as a teaching tool. Conclusion:A simple model based on human anatomy has been created to allow careful study of BPPV pathophysiology and treatment. Going forward, this tool could offer insights that may lead to more ac-curate diagnosis and treatment of BPPV. Copyright a 2016 Chinese Medical Association. Production and hosting by Elsevier B.V. on behalf of KeAi Communications Co., Ltd. This is an open access article under the CC BY-NC-SA license (http://creativecommons.org/licenses/by-nc-sa/4.0/).

New views on benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo(BPPV)is the most common vestibular peripheral disease,and has increasingly become the focus of research on vertigo diseases in recent years.In particular,otolaryngology and neurology societies worldwide have placed a greater focus on the study of BPPV.This article reviews the current diagnosis and treatment status and research progress of benign paroxysmal positional vertigo in China from the aspects of disease etiology,pathology,and pathophysiology.We will also consider potential future research in this field.

重复经颅磁刺激对育龄期前庭性偏头痛伴位置性眩晕患者疗效分析

目的探讨重复经颅磁刺激(repetitive transcranial magnetic stimulation,rTMS)对育龄期前庭性偏头痛(vestibular migraine,VM)伴位置性眩晕的疗效。方法收集如皋市人民医院神经内科、耳鼻咽喉科门诊育龄期VM伴位置性眩晕患者57例,进行一般情况、量表评价。采用随机数字法分为rTMS组和对照组,所有患者均予以规范非甾体止痛药物、抗眩晕药物治疗,rTMS组给予低频(1 Hz)rTMS作用于枕叶。分别采用SRM-IV眩晕诊疗系统、眼震电图行位置试验、温度试验评估前庭功能,采用眩晕障碍量表(dizziness handicap inventory,DHI),头痛程度视觉模拟量表(VAS)以及头痛影响测评量表(headache impact test-6,HIT-6)对治疗前、治疗2周、治疗3个月疗效评估。结果育龄期VM伴位置性眩晕患者发病年龄23~49(38.72±7.93)岁,52.63%(30/57)患者以后半规管受累为主,33.33%(19/57)患者温度试验异常。组间比较,治疗2周时对照组情绪(DHI-E)优于rTMS组,治疗3个月时rTMS组VAS、HIT-6评分改善程度显著优于对照组(P<0.05),其余时间段VAS、HIT-6、DHI组间比较无统计学差异。组内比较,治疗2周、治疗3个月与治疗前比较,rTMS组和对照组VAS、HIT-6、DHI评分均有统计学差异;治疗3个月与治疗2周比较时,rTMS组除躯体(DHI-P)外其余各评价指标均有统计学差异,对照组仅HIT-6评分、DHI-P存在统计学差异。结论低频rTMS能有效改善VM伴位置性眩晕患者头痛症状,改善眩晕症状并不优于单纯口服药物,随治疗时间延长,rTMS对头痛及眩晕改善越明显。

“Sitting-up vertigo as an expression of posterior semicircular canal heavy cupula and posterior semicircular canal short arm canalolithiasis”

Background:Vestibular symptoms on sitting-up are frequent on patients seen by vestibular specialists.Recently,a benign paroxysmal positional vertigo(BPPV)variant which elicits vestibular symptoms with oculomotor evidence of posterior semicircular canal(P-SCC)cupula stimulation on sitting-up was described and named sitting-up vertigo BPPV.A periampullar restricted P-SCC canalolithiasis was proposed as a causal mechanism.Objective:To describe new mechanisms of action for the sitting-up vertigo BPPV variant.Methods:Eighteen patients with sitting-up vertigo BPPV were examined with a pre-established set of positional maneuvers and follow-up until they resolved their symptoms and clinical findings.Results:All patients showed up-beating torsional nystagmus(UBTN)and vestibular symptoms on coming up from either Dix-Hallpike(DHM)or straight head-hanging maneuver.Sixteen out of 18 patients presented a sustained UBTN with an ipsitorsional component to the tested side on half-Hallpike maneuver(HH).A slower persistent contratorsional down-beating nystagmus was found in eleven out18 patients tested on nose down position(ND).Conclusions:Persistent direction changing positional nystagmus on HH and ND positions indicative of PSCC heavy cupula was found in 11 patients.A sustained UBTN on HH with the absence of findings on ND,which is suggestive of the presence of P-SCC short arm canalolithiasis,was found on 5 patients.All patients were treated with canalith repositioning maneuvers without success,but they resolved their findings by means of Brandt-Daroff exercises.We propose P-SCC heavy cupula and P-SCC short arm canalolithiasis as two new putative mechanisms for the sitting-up vertigo BPPV variant.

Comparisons of Supine Roll Test and Alternative Positional Tests in HC-BPPV Lateralization

Objective The purpose of the study was to evaluate the efficiency of the supine roll test(SRT)and alternative positional tests(APTs)including the bow and lean test(BLT),pseudo-spontaneous nystagmus(PSN),and lying down nystagmus(LDN)to identify the affected side in horizontal canal benign paroxysmal positional vertigo(HC-BPPV).Methods In our prospective study,we performed a testing profile(PSN,BLT,LDN,SRT)on 59 HC-BPPV patients using videonystagmography.We compared the accuracy and sensitivity of these tests in HC-BPPV lateralization.Data from 30 healthy patients were collected as the control group.Results When performing positional tests,the elicited nystagmus coinciding with Ewald’s second law was defined as a“positive response”.In 44 patients with geotropic nystagmus,the rates of positive response in LDN,PSN,and BLT were 22/44(50%),19/44(43%),and 18/44(41%),respectively,while in 15 patients with apogeotropic nystagmus,the positive response rates of these three tests were 10/15(66.7%),9/15(60%),and 4/15(27.00%),respectively.The sensitivity of LDN(54.38%)was higher than that of PSN(47.37%)and BLT(38.60%)but lower than that of SRT(89.47%).Notably,the accuracy rate of PSN(71.8%)was higher than that of the other APTs.In 6 patients with symmetrical nysgtamus during the roll test,5 patients showed a positive response in both LDN and BLT(83.34%),whereas 4 patients showed a positive response in PSN(66.67%).Conclusion All positional tests are helpful for determining the affected side of HC-BPPV,but SRT carries the highest accuracy of lateralization followed by PSN.

短期针刺治疗良性阵发性位置性眩晕复位后残余头晕的研究

目的观察短期针刺治疗良性阵发性位置性眩晕(BPPV)手法复位成功后残余头晕(residual dizziness,RD)症状的临床疗效。方法对手法复位成功后存在RD症状的BPPV患者80例,随机分为针刺组和对照组,每组40例。治疗组予短期针刺治疗,主穴为晕听区、平衡区等。常规针刺,留针30 min,1次/d,3次为一个疗程。对照组仅予以随访观察。分别于治疗前及治疗后第1、4周对两组患者进行眩晕障碍量表(dizziness handicap inventory,DHI)中文版及视觉模拟尺量表(VAS)评分,比较两组结果。结果治疗后第1周,除对照组中DHI情绪评分项目外,针刺组和对照组治疗后DHI各项评分、总分、VAS评分均较治疗前降低(P<0.05);治疗后第4周,针刺组和对照组治疗后DHI各项评分、总分、VAS评分均较治疗前及治疗后第1周降低(P<0.05);治疗后第1周,治疗组的DHI情绪、DHI功能评分、总分、VAS评分均低于对照组(P<0.05);治疗后第4周,治疗组的DHI功能评分及总分均低于对照组(P<0.05)。结论短期中医针刺治疗能有效减轻BPPV复位成功后的RD症状,尤其在发病后短期内能有效缓解患者头晕症状。

Affected-Ear-Up 90°Maneuver Proves That Nystagmus Does Not Occur by the Stimulation to the Macula of the Utricle

Background: The utricular macula is located on the floor of the utricle, approximately in the plane of the lateral semicircular canal, and is oriented to respond best to lateral tilts and side-to-side or fore-and-aft translations of the head. However, the details of the otolith ocular reflex are unknown. Pathophysiology of transient direction-changing geotropic positional nystagmus is a canalolithiasis in the lateral semicircular canal. The principle of affected-ear-up 90° maneuver is moving debris from a long arm to the utricle, therefore debris stimulates the utricular macula in the sitting position after the treatment. Objective: To clarify whether nystagmus occurs by the stimulation to the macula of the utricle. Methods: The subjects were 10 patients with lateral semicircular canal canalolithiasis. After the diagnosis, we performed affected-ear-up 90° maneuver immediately. We observed eye movements in the sitting position (chin-down 30°) just after the treatment. Results: No one showed nystagmus in the sitting position after the treatment. In all patients, positional nystagmus disappeared within 7 days after the treatment. Conclusion: Nystagmus does not occur by the stimulation to the macula of the utricle. Hence, we cannot assess the function of the utricle by the analysis of eye movements, and ocular counter-rolling is considered to be a semicircular canal ocular reflex.

改良李氏复位法和Epley法治疗后半规管良性阵发性位置性眩晕的疗效观察

目的 比较改良李氏复位法和Epley法治疗后半规管良性阵发性位置性眩晕(posterior canal benign paroxysmal positional vertigo,PC-BPPV)的疗效和复发情况。方法 研究对象为2019年1月~2020年10月接受诊疗的PC-BPPV患者共128例患者分为两组,分别接受改良李氏复位法(64例)及Epley法(64例)复位治疗。所有患者于治疗后1天、1周、1个月门诊复诊,观察疗效和复发情况。所有患者均随访3个月以上,观察治疗后复发情况。结果 治疗后1天时,Epley法治愈率优于改良李氏复位法(P<0.05)。1周、1个月两组疗效差异无统计学意义(P均>0.05)。治疗后3个月两组复发率差异无统计学意义(P>0.05)。结论改良李氏复位法和Epley法均为PC-BPPV的有效治疗方式。治疗方式的个性化选择,可结合患者身体状况,复位操作耐受程度等因素综合考虑。

Unilateral mimicking bilateral BPPV- a forgotten entity? Characteristics of a largecohort of patients, comparison with posterior canal BPPV and clinical implications

Objective: Unilateral mimicking bilateral benign paroxysmal positional vertigo (umb-BPPV) was attributed to inappropriate head positioning during testing of the posterior canal. Despite its inclusion in theDiagnostic criteria for the classification of vestibular disorders of the Barany Society, the clinical characteristics and treatment responsiveness of this BPPV subtype have not been intensively studied.Methods: Records of patients with BPPV seen at a single outpatient dizziness clinic during the years 2000e2020 were reviewed. Eighty seven patients with umb-BPPV and 86 random patients with posteriorcanal BPPV (p-BPPV) were retrieved. Their demographics and BPPV characteristics were analyzed.Results: Patients' and BPPV characteristics were similar in umb- and p-BPPV except for the prevalence ofmales in the umb-BPPV group. No differences were found between treatment responsiveness and recurrences in both groups. The recurrence rate of umb-BPPV was not influenced by age, gender, BPPV side,duration of symptoms or treatment responsiveness during the first attack.Conclusions: In accordance with our hypothesis about mixed canalo- and cupulolithiasis as the underlying mechanism of umb-BPPV, patients did not differ in characteristics and treatment responsivenessfrom p-BPPV patients. Recognition of umb-BPPV is important since inappropriate treatment can cause anunnecessary delay in therapy success.

Molecular Mediators of Estrogen Reduction-induced Otolith Shedding

Objective Previous study suggested that estradiol(E2)plays an important role in otolith shedding by regulating the expression of otoconin 90(OC90).The purpose of this article is to provide further data on the effect and mechanism of E2 on the morphology of otolith.Methods The rats receiving bilateral ovariectomy(OVX)were used as animal models.Co-immunoprecipitation was used to observe the relationship between estrogen receptor(ER)and estrogen-related receptorα(ERRα).The morphology of otolith was observed under the scanning electron microscopy.Western blotting and qPCR were used for quantitative analysis of the roles of ER and ERRαin regulating OC90 expression.Results The looser otoliths were observed in rats receiving bilateral OVX,which could be reversed by supplementation with E2.The level of ERRαwas decreased in bilateral OVX rats.ER and ERRαinteracted with each other on the regulation of the expression of OC90.Conclusion Our results suggest ER and ERRαare both important downstream receptors involved in regulating OC90 expression in utricles of rats,and ERRαprobably functions by interacting with ER.This provides evidence for the mechanism of otolith shedding.And it may be significant for future studies of targeted prevention and therapies for benign paroxysmal positional vertigo.