Benign paroxysmal positional vertigo

To compare the recovery rates of modified Epley's against Semont's manoeuvres in patients with posterior canal benign paroxysmal positional vertigo: a randomized clinical trial

INTRODUCTION

Benign paroxysmal positional vertigo (BPPV) is one of the commonest causes of peripheral vertigo. It is treated with various canalolith repositioning manoeuvres by changing the head positions to allow the otoconial debris to fall back from the affected canal back to the utricle. The present study has compared the rate of recovery of vertigo with modified Epley's manoeuvres as compared to Semont's manoeuvre in patients with posterior canal BPPV.

MATERIALS AND METHODS

One hundred and seventy patients diagnosed by positive Dix-Hallpike test as posterior canal BPPV were included in this clinical trial. Subjective analysis of vertigo was done using visual analogue scale. 85 patients each were recruited in two arms by simple randomization using lottery method. Modified Epley's manoeuvre was administered to one group and Semont's manoeuvre to the other. They were recalled after 2 weeks for clinical assessment with repeat Dix-Hallpike and VAS.

RESULTS

Repeat Dix-Hallpike manoeuvres after two weeks revealed that 95.3 and 90.6% patients improved in Modified Epley's and Semont's group, respectively. After the second manoeuvre, the resolution rate was significantly higher in Semont's manoeuvre 100% (8 out of 8 patients), as compared to 25% (1 out of 4 patients) in Modified Epley's manoeuvre. Comparison of the mean values of VAS day 0 and VAS 2 weeks has been found to be statistically significant (p value of < 0.001).

CONCLUSION

Both Epley's and Semont's manoeuvre are equally efficacious in treatment of BPPV. However, use of Semont's manoeuvre required fewer repeat manoeuvres for complete resolution of symptoms in patients. The Semont's manoeuvre is also comparatively easier to perform with less number of position changes, takes less time, and has no requirement of post-manoeuvre mobility restrictions. Hence, it is recommended that Semont's manoeuvre can be routinely used for the management of PC BPPV especially in older population and patients with spinal problems.

A cross-sectional survey of non-specialist Australian audio-vestibular clinical practice for traumatic brain injury and rehabilitation

OBJECTIVE

This study explored non-specialist audiological clinical practice in the context of traumatic brain injury (TBI), and whether such practices incorporated considerations of TBI-related complexities pertaining to identification, diagnosis and management of associated auditory and vestibular disturbances.

DESIGN

A cross-sectional online survey exploring clinical practice, TBI-related training and information provision was distributed to audiologists across Australia via Audiology Australia and social media. Fifty audiologists, 80% female and 20% male, participated in this study. Years of professional practice ranged from new graduate to more than 20 years of experience.

RESULTS

Clear gaps of accuracy in knowledge and practice across all survey domains relating to the identification, diagnosis and management of patients with auditory and/or vestibular deficits following TBI were evident. Further, of the surveyed audiologists working in auditory and vestibular settings, 91% and 86%, respectively, reported not receiving professional development for the diagnosis and management of post-traumatic audio-vestibular deficits.

CONCLUSION

Inadequate resources, equipment availability and TBI-related training may have contributed to the gaps in service provision, influencing audiological management of patients with TBI. A tailored TBI approach to identification, diagnosis and management of post-traumatic auditory and vestibular disturbances is needed.

Early treatment for benign paroxysmal positional vertigo secondary to sudden sensorineural hearing loss

Sudden sensorineural hearing loss (SSNHL) accompanied by benign paroxysmal positional vertigo (BPPV) is relatively common in the clinic. There are unified standards for the treatment of primary BPPV with good reduction effect, while there are few studies on the treatment of BPPV secondary to SSNHL within 1 week of onset. The study was to investigate the treatment of BPPV secondary to SSNHL and compare its manual reduction with that of primary BPPV. We selected 90 patients with BPPV accompanied by SSNHL within a week of onset and 210 primary BPPV patients at Hebei Provincial Eye Hospital from June 2020 to December 2022. The former group was divided into the medicine group and manual reduction plus medicine group. The medicines used were extract of Ginkgo biloba leaves injection, betahistine hydrochloride injection and oral prednisone. We contrasted the efficacy respectively for posterior semicircular canal BPPV (psc-BPPV), horizontal semicircular canal BPPV (hsc-BPPV) and multiple semicircular canal BPPV (msc-BPPV). In addition, we compared the manual reduction effect for primary BPPV and manual reduction group, and the evaluation of efficacy are the intensity of nystagmus and the clinical symptoms. In the secondary BPPV group, there was no difference in efficacy between the medicine group and manual reduction group at the 7th-day after reduction for psc-BPPV, hsc-BPPV, and msc-BPPV (P > .05). The immediate effect of reduction was significantly different between the primary BPPV group and the group with SSNHL and BPPV for both psc-BPPV and hsc-BPPV (P < .05), and the effect of the primary BPPV group was better, but it was no difference for msc-BPPV (P > .05). For the treatment of BPPV accompanied by SSNHL within 1 week of onset, the additional reduction therapy showed no benefit, so we need to apply medication for SSNHL.

Paroxysmal Positional Nystagmus in Acoustic Neuroma Patients

The association between acoustic neuroma and positional vertigo with paroxysmal positional nystagmus is relatively rare, but, when present, it certainly represents a challenge for the otoneurologist. There are few reports in the literature on this particular issue, and some questions are still unanswered, particularly regarding the characteristics of positional nystagmus that may distinguish between a true benign paroxysmal vertigo and a positional nystagmus associated with the tumor. We present the videonystagmographic patterns of seven patients with acoustic tumor who had paroxysmal positional nystagmus and analyzed its features. A concomitant true benign paroxysmal positional vertigo may be present during the follow-up of a non-treated patient, as the paroxysmal positional vertigo may be the first symptom of the tumor, and it may show characteristics that are very similar to a posterior semicircular canal canalolithiasis or a horizontal canal "heavy or light cupula". The possible mechanisms are discussed.

Prevalence of Vestibular Disorders in Independent People Over 50 That Experience Dizziness

People aged over 50 are the most likely to present to a physician for dizziness. It is important to identify the main cause of dizziness in order to develop the best treatment approach. Our goal was to determine the prevalence of benign paroxysmal positional vertigo (BPPV), and peripheral and central vestibular function in people that had experienced dizziness within the past year aged over 50. One hundred and ninety three community-dwelling participants aged 51–92 (68 ± 8.7 years; 117 females) were tested using the clinical and video head impulse test (cHIT and vHIT) to test high-frequency vestibular organ function; the head thrust dynamic visual acuity (htDVA) test to test high-frequency visual-stability; the dizziness handicap inventory (DHI) to measure the impact of dizziness; as well as sinusoidal and unidirectional rotational chair testing to test low- to mid-frequency peripheral and central vestibular function. From these assessments we computed the following measures: HIT gain; htDVA score; DHI score; sinusoidal (whole-body; 0.1–2 Hz with 30°/s peak-velocity) vestibulo-ocular reflex (VOR) gain and phase; transient (whole-body, 150°/s² acceleration to 50°/s constant velocity) VOR gain and time constant; optokinetic nystagmus (OKN) gain and time constant (whole-body, 50°/s constant velocity rotation). Our study showed that BPPV, and peripheral or central vestibular hypofunction were present in 34% of participants, suggesting a vestibular cause to their dizziness. Over half (57%) of these with a likely vestibular cause had BPPV, which is more than twice the percentage reported in other dizzy clinic studies. Our findings suggest that the physical DHI score and VOR time constant were best at detecting those with non-BPPV vestibular loss, but should always be used in conjunction with cHIT or vHIT, and that the htDVA score and vHIT gain were best at detecting differences between ipsilesional and contralesional sides.

Identification of a genetic variant underlying familial cases of recurrent benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo in humans, yet the molecular etiology is currently unknown. Evidence suggests that genetic factors may play an important role in some cases of idiopathic BPPV, particularly in familial cases, but the responsible genetic variants have not been identified. In this study, we performed whole exome sequencing [including untranslated regions (UTRs)] of 12 families and Sanger sequencing of additional 30 families with recurrent BPPV in Caucasians from the United States (US) Midwest region, to identify the genetic variants responsible for heightened susceptibility to BPPV. Fifty non-BPPV families were included as controls. In silico and experimental analyses of candidate variants show that an insertion variant rs113784532 (frameshift causing truncation) in the neural cadherin gene PCDHGA10 (protocadherin-gamma A10) is an exceedingly strong candidate (p = 1.80x10-4 vs. sample controls; p = 5.85x10-19 vs. ExAC data; p = 4.9x10-3 vs. NHLBI exome data). The mutant protein forms large aggregates in BPPV samples even at young ages, and affected subjects carrying this variant have an earlier onset of the condition than those without [average 44.0±14.0 (n = 16) versus 54.4±16.1 (n = 36) years old, p = 0.054]. In both human and mouse inner ear tissues, PCDHGA10 is expressed in ganglia, hair cells and vestibular transitional epithelia. Fluorescent RNA in situ hybridization using mouse inner ear tissues shows that expression increases with age. In summary, our data show that a variant in the PCDHGA10 gene may be involved in causing or aggravating some familial cases of recurrent idiopathic BPPV.

Traumatic benign paroxysmal positional vertigo: personal experience and comparison with idiopathic BPPV

OBJECTIVE

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vestibular vertigo, with post-traumatic origin in about 15% of cases. Management and prognosis of traumatic BPPV (T-BPPV) are still debated, especially about recurrence. The aim was to compare T-BPPV to idiopathic (I-BPPV).

DESIGN AND STUDY SAMPLE

We analysed data about 795 BPPV patients: 716 idiopathic (90%) and 79 post-traumatic (10%), evaluating clinical history and bedside-examination, treating all patients with repositioning manoeuvres and reassessing them until the resolution of symptoms and nystagmus.

RESULTS

Persistence rate in T-BPPV and I-BPPV patients was significantly different (p = 0.0074, OR = 2.31), respectively 12.6% and 5%. Also the rate of bilateral disease (p = 0.0063, OR = 4.72) and multicanalar involvement (p = 0.0183; OR = 4.67) were significantly higher in T-BPPV patients . There were no significant differences in age and sex distribution, side and canal interested. In T-BPPV group, the resolution rate with one manoeuvre was lower than I-BPPV (p = 0.0132: OR: 0,56). Recurrence rate was 38% in the T-BPPV group and 30.6% in the I-BPPV group, without significant difference.

CONCLUSIONS

T-BPPV resulted different from I-BPPV in the resolution rate, bilateral or multiple canal involvement and persistence rate. T-BPPV and I-BPPV does not differ for recurrence rate, suggesting that, after resolution, the natural course of post-traumatic and idiopathic BPPV is similar.

Simultaneous Presentation of Benign Paroxysmal Positional Vertigo and Meniere's Disease - Case Report

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is one of the most common clinical entities, which develops spontaneously in most of the cases, but it can be secondary as a result of different conditions such as head injuries, viral neurolabyrinthitis, Meniere's disease and vertebrobasilar ischemia. The aim of presenting this case is to point out to the need of taking a precise clinical history and performing Dix-Hallpike manoeuvre in all patients who complain about vertigo regardless of the previously diagnosed primary disease of the inner ear.

CASE PRESENTATION

A 63-year-old female patient presented with the classical triad of symptoms for Meniere's disease (fluctuating sensorineural hearing loss in the right ear, tinnitus and fullness in the same ear and rotary vertigo), two years later complained of brief episodes of vertigo linked to changes in head position relative to gravity. Dix-Hallpike manoeuvre showed a classical response in the head-hanging right position. Benign paroxysmal positional vertigo (BPPV) in the same ear was diagnosed in this patient. After treatment with Epley's canal repositioning manoeuvre for a few days, the symptoms of positional vertigo resolved.

CONCLUSION

The authors recommend complete audiological and otoneurological evaluation in all patients with vertigo for timely recognition/diagnosis of any inner ear associated pathology.

Benign paroxysmal positional vertigo associated with Meniere's disease

OBJECTIVE

We studied the clinical features of benign paroxysmal positional vertigo (BPPV) associated with Meniere's disease.

METHODS

The medical records of 120 patients with BPPV was retrospectively analyzed. Complete otolaryngological, audiological, and neurotological evaluation results were available for all patients, including nystagmography. All patients were diagnosed using the Dix-Hallpike test or roll test and treated with the canalith repositioning procedure. The outcomes were compared among the three groups.

RESULTS

A series of 120 BPPV cases. Results showed that Group A and Group B based on the following features: unilateral semicircular canal BPPV occurred more often than bilateral BPPV and the posterior semicircular canal was the most common canal involved. Additionally, Meniere's disease patients with multiple semicircular canal BPPV required repeated canalith repositioning procedures and had a higher recurrence rate.

CONCLUSION

A lower treatment success rate and a higher recurrence rate were found in the BPPV patients with Meniere's disease compared with the patients without Meniere's disease. The recurrence rate was highest in the patients with multiple semicircular canal BPPV with Meniere's disease.

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

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

The Interrelations Between Different Causes of Dizziness: A Conceptual Framework for Understanding Vestibular Disorders

Background:

According to population-based studies that estimate disease prevalence, the majority of patients evaluated at dizziness clinics receive a single vestibular diagnosis. However, accumulating literature supports the notion that different vestibular disorders are interrelated and often underdiagnosed.

Objective:

Given the complexity and richness of these interrelations, we propose that a more inclusive conceptual framework to vestibular diagnostics that explicitly acknowledges this web of association will better inform vestibular differential diagnosis.

Methods:

A narrative review was performed using PubMed database. Articles were included if they defined a cohort of patients, who were given specific vestibular diagnosis. The interrelations among vestibular disorders were analyzed and placed within a conceptual framework.

Results:

The frequency of patients currently receiving multiple vestibular diagnoses in dizziness clinic is approximately 3.7% (1263/33 968 patients). The most common vestibular diagnoses encountered in the dizziness clinic include benign paroxysmal positional vertigo (BPPV), vestibular migraine, vestibular neuritis, and Ménière’s disease.

Conclusions:

A review of the literature demonstrates an intricate web of interconnections among different vestibular disorders such as BPPV, vestibular migraine, Ménière’s disease, vestibular neuritis, bilateral vestibulopathy, superior canal dehiscence syndrome, persistent postural perceptual dizziness, anxiety, head trauma, and aging, among others.

Benign Paroxysmal Positional Vertigo After Oral and Maxillofacial Surgery: Our Experience and Review of Literature

Objectives

The aim of our study is to evaluate the influence of patient risk factors and the length of surgical time on the onset of BPPV (benign paroxysmal positional vertigo) and suggest surgical and clinical strategies to prevent this rare complication.

Method

Our retrospective study analyzes that, in 2 years, 281 patients, divided into three groups, underwent wisdom teeth extraction, sinus lift elevation and orthognathic surgery, at the Oral and Maxillofacial Department of the University of Naples "Federico II."

Results

Twenty-one patients presented postoperative BPPV. Some comorbidities, like dyslipidemia, high cholesterol levels, vascular problems, endocrinological disorders, perimenopausal age, female gender, cranial trauma, neurologic disorders, migraine, hypovitaminosis D, autoimmune disease, flogosis of inner ear, can be risk factors to the occurrence of postoperative vertigo.

Conclusion

Our statistical analysis revealed a relationship between surgical time and comorbidity and onset of vertigo for each group of patients.

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.

Patient, disease, and outcome characteristics of benign paroxysmal positional vertigo with and without Meniere's disease

BACKGROUND

Meniere's disease (MD)-associated benign paroxysmal positional vertigo (BPPV) is complex and difficult to diagnose, and reports of its prevalence, pathologic features and outcomes are sparse and conflicting.

OBJECTIVE

Report disease characteristics and outcomes associated with the presence of MD in patients with BPPV.

MATERIALS/METHODS

A retrospective study of patients with BPPV between 2007 and 2017 at a single, high-volume institution.

RESULTS

Of 1581 patients with BPPV identified, 7.1% had MD and 71.9% of those patients had BPPV in the same ear(s) as MD. Patients with MD were more likely to have lateral semicircular canalithiasis (11.6% vs. 5.5%, p = .009) and multiple canalithiasis (7.1% vs. 2.5%, p = .005). MD was associated with an increased rate of resolution of BPPV (p = .008) but also increased time to resolution (p = .007). There was no association between MD and recurrence of BPPV.

CONCLUSIONS

MD is associated with lateral canalithiasis. Contrary to prior reports, BPPV in MD can affect either ear and was not associated with poorer outcomes than idiopathic BPPV.

SIGNIFICANCE

The largest series to date investigating disease and outcome characteristics for BPPV in MD is presented. These data inform diagnosis and expectations in the management of these complex patients.

Healing criteria: How should an episode of benign paroxistic positional vertigo of posterior semicircular canal's resolution be defined? Prospective observational study

OBJECTIVES

To compare the outcome of the Epley maneuver (EM) in benign paroxysmal positional vertigo of the posterior canal (CSP-BPPV) depending on the definition used for recovery.

DESIGN

Multicenter observational prospective study.

SETTING

Otoneurology Units of 5 tertiary reference hospitals.

PARTICIPANTS

All patients presenting with unilateral CSP-BPPV assisted for 1-year period.

EXCLUSION CRITERIA

Spontaneous nystagmus, positive McClure-Pagnini maneuver, positive bilateral Dix-Hallpike maneuver (DHM), positive DHM for vertigo but negative for nystagmus and atypical nystagmus.

MAIN OUTCOME MEASURES

Response to EM was measured after 7 days in 3 different outcomes: disappearance of nystagmus during the DHM in the follow-up visit, disappearance of vertigo during the DHM and general status (GS) during daily life activities.

RESULTS

264 patients were recruited (68 male/166 female, mean age 62 years). After the EM, nystagmus disappeared in 67% of them, vertigo in 54% and 36% were asymptomatic in their daily life. These outcomes were strongly correlated, but they were not concordant in a clinically significant group of cases; only the 26% of patients met all of them. The healing process follows the next sequence: negativization of positional nystagmus, then disappearance of positional vertigo and, finally, the improvement of GS during daily life activities.

CONCLUSION

Nowadays, healing criteria for the resolution of an PSC-BPPV episode have not been specifically defined yet. Provided that other otoneurological disorders have been ruled out, the next resolution criterion is proposed: absence of nystagmus and specifically during control DHM and disappearance of symptoms during daily life activities.

Development and face validation of a Virtual Reality Epley Maneuver System (VREMS) for home Epley treatment of benign paroxysmal positional vertigo: A randomized, controlled trial

PURPOSE

To develop and validate a smartphone based Virtual Reality Epley Maneuver System (VREMS) for home use.

METHODS

A smartphone application was designed to produce stereoscopic views of a Virtual Reality (VR) environment, which when viewed after placing a smartphone in a virtual reality headset, allowed the user to be guided step-by-step through the Epley maneuver in a VR environment. Twenty healthy participants were recruited and randomized to undergo either assisted Epleys or self-administered Epleys following reading instructions from an Instructional Handout (IH). All participants were filmed and two expert Otologists reviewed the videos, assigning each participant a score (out of 10) for performance on each step. Participants rated their perceived workload by completing a validated task-load questionnaire (NASA Task Load Index) and averages for both groups were calculated.

RESULTS

Twenty participants were evaluated with average age 26.4±7.12years old in the VREMS group and 26.1±7.72 in the IH group. The VR assisted group achieved an average score of 7.78±0.99 compared to 6.65±1.72 in the IH group. This result was statistically significant with p=0.0001 and side dominance did not appear to play a factor. Analyzing each step of the Epley maneuver demonstrated that assisted Epleys were done more accurately with statically significant results in steps 2-4. Results of the NASA-TLX scores were variable with no significant findings.

CONCLUSION

We have developed and demonstrated face validity for VREMS through our randomized controlled trial. The VREMS platform is promising technology, which may improve the accuracy and effectiveness of home Epley treatments.

LEVEL OF EVIDENCE

N/A.

Our experience with 500 patients with benign paroxysmal positional vertigo: Reexploring aetiology and reevaluating MRI investigation

OBJECTIVE

To explore the aetiology of and to evaluate the importance of MRI investigation on the posterior semicircular canal benign paroxysmal positional vertigo in an Irish population.

METHODS

A retrospective observational study of 500 patients with posterior semicircular canal benign paroxysmal positional vertigo, diagnosed and treated by the senior author over a 10-year period. Most patients underwent an MRI brain and inner ear, following the same scan protocol. This included T1 weighted sagittal IR-FSPGR volume, axial T2 weighted, gradient echo T2 weighted and FLAIR sequences plus time of flight cerebral angiography.

RESULTS

The average age of presentation was 56 years; with the overall female to male ratio was 1.6:1, which was largely the net results of 2 age groups. Over 30% of our patients recalled distinct aetiological triggers, of which the top 3 were trauma, infection, and surgery. These accounted for 16%, 6%, and 5%, respectively. More than 25% of the patients were discovered to have abnormal intracranial findings on MRI. The 2 most common non-infarct incidental findings were neoplasia and vascular abnormalities. Although fewer than 20 patients had acute intracranial haemorrhage or malignant tumours, most of them were urgently referred to neurosurgeon due to the life-threatening nature of the condition. One round of particle repositioning manoeuver was successful in treating 84% of the patients, and the 2-year recurrence rate was only 2.2%.

CONCLUSION

The diagnosis of posterior semicircular canal benign paroxysmal positional vertigo is thought to be relatively easy to make, and the treatment is highly effective. Clinicians should be fully aware of and prepared for the diverse aetiology, and thus have no hesitation in requesting MRI scan as an important investigation.

Two Common Second Causes of Dizziness in Patients With Ménière's Disease

OBJECTIVE

There are no epidemiological studies quantifying the prevalence of second causes of dizziness in Ménière's disease (MD). Therefore, we aimed to quantify which dizziness-inducing causes are prevalent alongside MD. Moreover, we analyzed which second cause of dizziness was more common in a specific age group and if age was a risk factor.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary referral center.

METHODS

Data were retrospectively obtained from all MD patients who visited our clinic between January 2000 and December 2013. Workup included vestibular tests, pure tone audiometry, blood pressure monitoring, and the hyperventilation provocation test, the Nijmegen Questionnaire (NQ) and the Hospital Anxiety and Depression Scale (HADS). The final causes of dizziness were based on consensus between an ENT-surgeon and a neurologist who were consulted simultaneously.

RESULTS

We found that 143 (30%) of 469 MD patients suffered from a second cause of dizziness. The two most common causes were psychological distress (PD) (70%) and benign paroxysmal positional vertigo (BPPV) (18%). The mean age for MD patients with PD was 58.7 ± 13.3 years compared with the mean age of 63.9 ± 14.3 years for MD patients without PD (mean difference = -5.2 years, 95% CI: -8.3 to -2.2, p = 0.001). MD patients younger than 60 of age had a 15% higher risk of suffering from psychological distress than those who were older than 60 (risk difference, 15%, 95% CI, 7.0-22%). Age could not be identified as a risk factor for BPPV in older MD patients.

CONCLUSIONS

In 30% of the patients with MD a second cause of dizziness is present. PD most commonly coincides with MD, especially in younger patients. The second most common cause is BPPV.

Is Alteration of Tuning Property in Cervical Vestibular-Evoked Myogenic Potential Specific for Ménière's Disease?

OBJECTIVE

The aim of this study is to show sensitivity and specificity of cervical vestibular-evoked myogenic potential (cVEMP) tuning property test to Ménière's disease (MD) in comparison with healthy controls (HC) and patients with other vestibular diseases.

SUBJECTS

Totally 92 subjects (50 women and 42 men, 20-77 years of age) were enrolled in this study. Subjects were composed of 38 definite unilateral MD patients, 11 unilateral benign paroxysmal positional vertigo patients, 14 vestibular migraine patients, 19 unilateral vestibular neuritis patients, and 10 HC.

METHODS

The subjects underwent cVEMP testing to 500 and 1,000 Hz short tone bursts (125 dBSPL). The corrected amplitudes of the first biphasic responses (p13-n23) (cVEMP) were measured. Then, a tuning property index (the 500-1,000 Hz cVEMP slope) was calculated.

RESULTS

The area of under the ROC curve (AUC) was 0.75 in comparison with other vestibular disease patients, while AUC was 0.77 in comparison with other vestibular disease patients plus HC. The best cutoff point of the 500-1,000 Hz cVEMP slope was -19.9. Sensitivity of the tuning property test to MD was 0.74, while specificity was 0.76 to other vestibular disease patients.

CONCLUSION

The tuning property test of cVEMP is useful as a screening test of MD.

Migraine and benign paroxysmal positional vertigo: a single-institution review

Background:

Benign paroxysmal positional vertigo and migraine-associated dizziness are common. The prevalence of benign paroxysmal positional vertigo seems to be higher in patients with migraine-associated dizziness than in those without migraine.

Methods:

A database of 508 patients seen at the primary author's balance clinic was analysed to determine the prevalence of migraine, as defined by International Headache Society criteria, in patients with benign paroxysmal positional vertigo.

Results:

The percentage of patients with dizziness or vertigo who met criteria for migraine was 33.7 per cent, with a prevalence of benign paroxysmal positional vertigo of 42.3 per cent. When excluding patients with migrainous vertigo, patients with migraine frequently had benign paroxysmal positional vertigo (66.7 per centvs55.8 per cent), although this finding was not statistically significant.

Conclusion:

The results for the entire sample suggest that, after excluding patients with migrainous vertigo, patients with migraine seem more likely to have benign paroxysmal positional vertigo; however, this association was not significant, probably because of the small sample size.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)

Objective

This update of a 2008 guideline from the American Academy of Otolaryngology—Head and Neck Surgery Foundation provides evidence-based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV.

Purpose

The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life of individuals afflicted with BPPV.

Action Statements

The update group made strong recommendations that clinicians should (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, and (2) treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. The update group made a strong recommendation against postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. The update group made recommendations that the clinician should (1) perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus; (2) differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo; (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling; (4) reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms; (5) evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders; and (6) educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The update group made recommendations against (1) radiographic imaging for a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, (2) vestibular testing for a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, and (3) routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. The guideline update group provided the options that clinicians may offer (1) observation with follow-up as initial management for patients with BPPV and (2) vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV.

Development of a murine model of traumatic benign paroxysmal positional vertigo: a preliminary study

CONCLUSION

The results showed a gradual detachment of otoconia in the utricle after a single event of head vibration, possibly explaining the frequent recurrence of BPPV attacks and persistent dizziness after trauma.

OBJECTIVES

This study developed a murine model of traumatic BPPV and observed the changes in otoconia detachment over time.

METHODS

Six-week-old CBA mice were used in this study. Otoconia detachment was induced by vibrating the head for 2 min. Utricles of mice were harvested from different groups: before the head vibration and 1 day, 1 week, 1 month, and 3 months after vibration application. Using scanning electron microscopy and ImageJ software, the percentage of the intact area of otoconia in the utricle was calculated. Hearing thresholds were compared among the groups.

RESULTS

The mean (± SD) percentages of the intact area of otoconia in the utricle were 98.1% ± 1.7% before the vibration and 93.6% ± 1.7%, 88.9% ± 5.3%, 78.2% ± 20.9%, and 38.9% ± 24.1% at 1 day, 1 week, 1 month, and 3 months after the vibration, respectively. The percentage decreased significantly over time after the vibration (p < .001). The hearing thresholds were not different among the groups.

Spatiotemporal differences in otoconial gene expression

Otoconia are minute biocrystals composed of glycoproteins, proteoglycans, and CaCO₃ , and are indispensable for sensory processing in the utricle and saccule. Otoconia abnormalities and degeneration can cause or facilitate crystal dislocation to the ampulla, leading to vertigo and imbalance in humans. In order to better understand the molecular mechanism controlling otoconia formation and maintenance, we have examined the spatial and temporal expression differences of otoconial genes in the mouse inner ear at developmental, mature and aging stages using whole transcriptome sequencing (RNA-Seq) and quantitative RT-PCR. We show that the expression levels of most otoconial genes are much higher in the utricle and saccule compared with other inner ear tissues before postnatal stages in C57Bl/6J mice, and the expression of a few of these genes is restricted to the embryonic utricle and saccule. After the early postnatal stages, expression of all otoconial genes in the utricle and saccule is drastically reduced, while a few genes gain expression dominance in the aging ampulla, indicating a potential for ectopic debris formation in the latter tissue at old ages. The data suggest that the expression of otoconial genes is tightly regulated spatially and temporally during developmental stages and can become unregulated at aging stages. Birth Defects Research (Part A) 106:613-625, 2016. © 2016 Wiley Periodicals, Inc.

Sudden sensorineural hearing loss with positional vertigo: Initial findings of positional nystagmus and hearing outcomes

OBJECTIVES

To investigate the initial findings of positional nystagmus in patients with sudden sensorineural hearing loss (SSNHL) and positional vertigo, and to compare hearing improvement among patients with different types of positional nystagmus.

DESIGN

The characteristics of positional nystagmus upon initial examination were analysed, and the initial mean pure-tone audiometry (PTA) threshold was compared with that at three months after treatment.

STUDY SAMPLE

Forty-four SSNHL patients with concomitant positional vertigo were included.

RESULTS

Positional nystagmus was classified into five subgroups; persistent geotropic direction-changing positional nystagmus (DCPN) in head-roll test (HRT) and negative Dix-Hallpike test (DHT), persistent apogeotropic DCPN in HRT and negative DHT, positive DHT and negative HRT, persistent geotropic DCPN in HRT and positive DHT, and persistent apogeotropic DCPN in HRT and positive DHT. PTA threshold improvement was significantly greater in SSNHL patients with negative DHT than with positive DHT (p = 0.027).

CONCLUSIONS

When geotropic DCPN was elicited by HRT, the nystagmus was persistent, which suggests that alteration of specific gravity of the endolymph, rather than the lateral canal canalolithiasis, may be a cause of this characteristic positional nystagmus. Positive DTH may be a prognostic factor for worse hearing recovery among patients with SSNHL and positional vertigo.

Benign Positional Vertigo: Prognostic Factors

OBJECTIVE/HYPOTHESIS: We sought to assess prognostic factors associated with initial successful treatment and recurrence of benign paroxysmal positional vertigo (BPPV) with the canalith repositioning (CRP) maneuver with mastoid vibration. STUDY DESIGN AND SETTING: We conducted a retrospective chart review of 104 consecutive BPPV patients at a tertiary care referral center during 1999.

METHODS: The main outcome measures were resolution of BPPV and absence of nystagmus on Hallpike maneuver.

RESULTS: Ninety-three patients (89.4%) experienced initial symptom resolution, and 21 of the initially successful patients had a recurrence (recurrence rate of 22.6%). Prior trauma or labyrinthitis was found to predict the lowest initial CRP success. Endolymphatic hydrops and central nervous system-related dizziness as cofactors with BPPV were associated with the highest recurrence rates.

CONCLUSION AND SIGNIFICANCE: Specific concurrent otologic conditions are associated with different outcomes in BPPV. (Otolaryngol Head Neck Surg 2004;130:426-9.)

BPPV and Variants: Improved Treatment Results with Automated, Nystagmus-Based Repositioning

OBJECTIVE: Although classical benign paroxysmal positional vertigo has generally been resolvable by routine manual repositioning maneuvers, nevertheless resistant cases and variants remain a significant problem. We investigated the efficacy of analyzing and treating positional vertigo with a system that provides unlimited, automated maneuverability of the patient while maintaining constant electronic monitoring of nystagmus.

STUDY DESIGN AND SETTING: A power-driven, multi-axial positioning chair combined with ongoing infrared video-oculography was used to manage 986 subjects in a tertiary clinical setting with complaints of positional vertigo. A nystagmus-based strategy and condition-specific protocols were used.

RESULTS: Significantly enhanced treatment outcomes were achieved, especially regarding intransigent and variant forms. Pertinent correlations were noted.

CONCLUSION: This multi-axial positioning chair combination provided enhanced diagnostic and treatment capabilities for managing positional vertigo, apparently due to improved analytical capability, precision repeatability, and unlimited 360-degree maneuverability.

SIGNIFICANCE: This advancement should be considered for tertiary management of complicated labyrinthine lithiasis.

Behavior of the Posterior Semicircular Canal After Dix-Hallpike Maneuver

The objective of the present study is to analyze the quantitative vestibulo-ocular responses in a group of patients with benign paroxysmal positional vertigo (BPPV) canalolithiasis and compare these data with the data of the tridimensional biomechanical model. This study was conducted on 70 patients that presented idiopathic posterior semicircular canal canalolithiasis. The diagnosis was obtained by Dix-Hallpike maneuvers recorded by videonystagmograph. The present study demonstrates that there is a significant correlation between the intensity of the nystagmus and its latency in cases of BPPV-idiopathic posterior semicircular canal canalolithiasis type. These findings are in agreement with those obtained in a tridimensional biomechanical model and are not related to the patients’ age.

Prevalence of Vestibular Disorder in Older People Who Experience Dizziness

Dizziness and imbalance are clinically poorly defined terms, which affect ~30% of people over 65 years of age. In these people, it is often difficult to define the primary cause of dizziness, as it can stem from cardiovascular, vestibular, psychological, and neuromuscular causes. However, identification of the primary cause is vital in determining the most effective treatment strategy for a patient. Our aim is to accurately identify the prevalence of benign paroxysmal positional vertigo (BPPV), peripheral, and central vestibular hypofunction in people aged over 50 years who had experienced dizziness within the past year. Seventy-six participants aged 51–92 (mean ± SD = 69 ± 9.5 years) were tested using the head thrust dynamic visual acuity (htDVA) test, dizziness handicap inventory (DHI), as well as sinusoidal and unidirectional rotational chair testing, in order to obtain data for htDVA score, DHI score, sinusoidal (whole-body, 0.1–2 Hz with peak velocity at 30°/s) vestibulo-ocular reflex (VOR) gain and phase, transient (whole-body, acceleration at 150°/s² to a constant velocity rotation of 50°/s) VOR gain and time constant (TC), optokinetic nystagmus (OKN) gain, and TC (whole-body, constant velocity rotation at 50°/s). We found that BPPV, peripheral and central vestibular hypofunction were present in 38 and 1% of participants, respectively, suggesting a likely vestibular cause of dizziness in these people. Of those with a likely vestibular cause, 63% had BPPV; a figure higher than previously reported in dizziness clinics of ~25%. Our results indicate that htDVA, sinusoidal (particularly 0.5–1 Hz), and transient VOR testing were the most effective at detecting people with BPPV or vestibular hypofunction, whereas DHI and OKN were effective at only detecting non-BPPV vestibular hypofunction.

Evaluation of quality of life pre- and post-vestibular rehabilitation in patients with benign paroxysmal positional vertigo associated with Meniere's disease

Introduction: Vertigo is a symptom that impacts the patients' quality of life and may force them to cease performing activities of daily living. Here, we discuss benign paroxysmal positional vertigo (BPPV) and Meniere's disease (MD), which show exacerbated symptoms when they appear in association. Vestibular rehabilitation (VR) is an effective treatment in reducing vertigo, especially in conjunction with other therapies.

Aim: To evaluate the quality of life of patients with BPPV and MD before and after VR.

Method: We conducted a descriptive observational qualitative and quantitative case study with 12 patients aged 35 to 86 years. All patients diagnosed with BPPV and MD received treatment in the ENT clinic. The Brazilian DHI questionnaire, which assesses the quality of life with a focus on physical, emotional, and functional aspects, was used for data collection, and was completed by patients before the first session and after the fifth session of VR. Data were tested using the Shapiro-Wilk normality test, followed by Wilcoxon, Friedman, and Spearman correlation tests (p < 0.05).

Results: There were significant improvements in scores for all aspects, with median changes ranging from 12 to 0 in the physical, 6 to 1 in the emotional, and 11 to 1 in the functional aspect. There were no correlations between the scores and sample characteristics.

Conclusion: VR was an effective method for the treatment of patients with BPPV and MD; it improves quality of life and shows the maximal influence on physical aspect scores, regardless of age or gender.

Why do treatment failure and recurrences of benign paroxysmal positional vertigo occur?

OBJECTIVE

To investigate the potential risk factors associated to the treatment failure and recurrence of benign paroxysmal positional vertigo (BPPV).

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary referral center.

PATIENTS

Four hundred patients with benign paroxysmal positional vertigo, 119 men and 281 women, aged 27 to 88 years.

INTERVENTION

Patients were treated once a week, with only one, appropriate, depending on the affected canal, repositioning maneuver (modified Epley, Semont, barbecue/inverted Gufoni, Kim). The control Dix-Hallpike test and the roll test were performed on 7 days.

MAIN OUTCOME MEASURES

The treatment outcome and recurrence were evaluated with regard to sex, age, duration of symptoms, etiologic factors, migraines, osteoporosis, vascular risk factors, endocrine diseases, localization of otoconia, and simultaneous involvement of multiple canals.

RESULTS

The results indicate that treatment was negatively affected by patients' age, osteoporosis, and head trauma, without them causing recurrent symptoms. The highest number of uncured patients was observed in the 73- to 88-year-old age group (14.8%). The application of more than one maneuver was necessary in 27.5% of cases with primary BPPV and 88.9% with secondary BPPV. The highest treatment success was achieved in the group with BPPV of the posterior semicircular canal (F = 3.668, p = 0.026). The recurrence rate was 15.5%.

CONCLUSION

Potential risk factors associated to the treatment failure were as follows: the age older than 50, secondary BPPV, head trauma, the occurrence of osteoporosis, and localization of otoconia in the anterior semicircular canal. The analyzed factors did not have impact on the recurrence.

One-third of vertiginous episodes during the follow-up period are caused by benign paroxysmal positional vertigo in patients with Meniere's disease

CONCLUSION

In the present study, about one-third of patients with Meniere's disease developed benign paroxysmal positional vertigo (BPPV)-like attacks. Additionally, more than one-third of all vertigo attacks were BPPV-like attacks. Thus, vertigo attacks in patients with Meniere's disease must be carefully treated because the therapy for such vertigo attacks is totally different from the therapy for BPPV.

OBJECTIVE

Physicians sometimes encounter patients with previously diagnosed Meniere's disease who develop BPPV attacks during the course of clinical follow-up. In this study, we explored the frequency with which BPPV was involved in all vertiginous episodes among patients with Meniere's disease.

METHODS

This retrospective study involved 296 patients with Meniere's disease who visited Kyoto University Hospital. The diagnosis of Meniere's disease was based on the guidelines for the diagnosis of Meniere's disease proposed by the Committee on Hearing and Equilibrium. We judged the cause of vertigo as one of the following five types: (1) definite Meniere's disease attack, (2) suspicious Meniere's disease attack, (3) definite BPPV attack, (4) suspicious BPPV attack, or (5) unknown.

RESULTS

In all, 96 patients (32.8%) developed BPPV-like attacks, and 187 vertiginous episodes (37.9%) were caused by BPPV. The lateral semicircular canal was the most frequently involved canal.

Gender-based comorbidity in benign paroxysmal positional vertigo

It has been noted that benign paroxysmal positional vertigo (BPPV) may be associated with certain disorders and medical procedures. However, most studies to date were done in Europe, and epidemiological data on the United States (US) population are scarce. Gender-based information is even rarer. Furthermore, it is difficult to assess the relative prevalence of each type of association based solely on literature data, because different comorbidities were reported by various groups from different countries using different patient populations and possibly different inclusion/exclusion criteria. In this study, we surveyed and analyzed a large adult BPPV population (n = 1,360 surveyed, 227 completed, most of which were recurrent BPPV cases) from Omaha, NE, US, and its vicinity, all diagnosed at Boys Town National Research Hospital (BTNRH) over the past decade using established and consistent diagnostic criteria. In addition, we performed a retrospective analysis of patients' diagnostic records (n = 1,377, with 1,360 adults and 17 children). The following comorbidities were found to be significantly more prevalent in the BPPV population when compared to the age- and gender-matched general population: ear/hearing problems, head injury, thyroid problems, allergies, high cholesterol, headaches, and numbness/paralysis. There were gender differences in the comorbidities. In addition, familial predisposition was fairly common among the participants. Thus, the data confirm some previously reported comorbidities, identify new ones (hearing loss, thyroid problems, high cholesterol, and numbness/paralysis), and suggest possible predisposing and triggering factors and events for BPPV.

Benign paroxysmal positional vertigo after surgical drilling of the temporal bone

OBJECTIVE

To present the clinical characteristics of secondary BPPV after surgical drilling of the temporal bone.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary referral academic medical center.

PATIENTS

Ten patients who developed BPPV after surgical procedure of temporal bone drilling were identified from 965 subjects who underwent surgical drilling of the temporal bone at Seoul National University Bundang Hospital. The localization and lateralization of BPPV were based on positional test using video eye movement recording system and videonystagmography.

MAIN OUTCOME MEASURES

Onset of BPPV after surgery, distributions of involved semicircular canals, response to particle repositioning maneuver and factors that may influence the development of secondary BPPV after surgical drilling of the temporal bone.

RESULTS

Onset of positional vertigo was mostly within 3 days except 1 case (sixth postoperative day). Postoperative BPPV was usually in the contralateral ear in 9 cases (90%), which occurred predominantly on the contralateral horizontal canal in 8 patients (80%). Positional vertigo was resolved after repositioning maneuvers in every case. None of them showed aggravation of bone conduction threshold.

CONCLUSION

The incidence of BPPV after surgical drilling of the temporal bone was around 1%, and the horizontal semicircular canal of the contralateral ear was predominantly involved. Head position during surgery (head restriction to contralateral ear down) as well as limitation of head movement due to compressive mastoid bandage after surgery seems to be responsible for such predominance.

Experimental study on the aetiology of benign paroxysmal positional vertigo due to canalolithiasis: comparison between normal and vestibular dysfunction models

Objectives:

Using American bullfrog models under normal conditions and under vestibular dysfunction, we investigated whether mechanical vibration applied to the ear could induce otoconial dislodgement.

Methods:

Vibration was applied to the labyrinth of the bullfrog using a surgical drill. The time required for the otoconia to dislodge from the utricular macula was measured. Vestibular dysfunction models were created and the dislodgement time was compared with the normal models. The morphology of the utricular macula was also investigated.

Results:

In the normal models, the average time for otoconial dislodgement to occur was 7 min and 36 s; in the vestibular dysfunction models, it was 2 min and 11 s. Pathological investigation revealed that the sensory hairs of the utricle were reduced in number and that the sensory cells became atrophic in the vestibular dysfunction models.

Conclusion:

The otoconia of the utricle were dislodged into the semicircular canal after applying vibration. The time to dislodgement was significantly shorter in the vestibular dysfunction models than in the normal models; the utricular macula sustained significant morphological damage.

Otolithic membrane damage in patients with endolymphatic hydrops and drop attacks

OBJECTIVES

1. Evaluate the otolithic membrane in patients with endolymphatic hydrops (EH) and vestibular drop attacks (VDA) undergoing ablative labyrinthectomy. 2. Correlate intraoperative findings to archival temporal bone specimens of patients with EH.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center. SPECIMEN SOURCE: 1. Patients undergoing labyrinthectomy for incapacitating Ménière's disease (MD), delayed EH, VDA, or acoustic neuroma (AN) between 2004 and 2011. 2. Archival temporal bone specimens of patients with MD.

INTERVENTIONS

Ablative labyrinthectomy.

MAIN OUTCOME MEASURES

Examination of the utricular otolithic membrane.

RESULTS

The otolithic membrane of the utricle was evaluated intraoperatively in 28 patients undergoing labyrinthectomy. Seven (25%) had a history of VDA, 6 (21%) had delayed EH, 9 (32%) had MD, and 6 (21%) had AN. All patients with VDA showed evidence of a disrupted utricular otolithic membrane, whereas only 50% and 56% of patients with delayed EH and MD, respectively, demonstrated otolithic membrane disruption (p = 0.051). None of the patients with AN showed otolithic membrane disruption (p = 0.004). The mean thickness of the otolithic membrane in 5 archival temporal bone MD specimens was 11.45 micrometers versus 38 micrometers in normal specimens (p = 0.001).

CONCLUSION

The otolithic membrane is consistently damaged in patients with VDA. In addition, there is a significantly higher incidence of otolithic membrane injury in patients with MD and delayed EH compared with patients without hydrops, suggesting that the underlying pathophysiology in VDA results from injury to the otolithic membrane of the saccule and utricle, resulting in free-floating otoliths and atrophy.

Benign paroxysmal positional vertigo associated with Meniere's disease: epidemiological, pathophysiologic, clinical, and therapeutic aspects

OBJECTIVES

We studied the demographic, pathogenetic, and clinical features of benign paroxysmal positional vertigo (BPPV) associated with Meniere's disease.

METHODS

The medical records of patients with BPPV associated with Meniere's disease were reviewed. In all patients, results of a complete otolaryngological, audiological, and neurotologic evaluation, including nystagmography, were available. Patients with idiopathic BPPV were used as a control group.

RESULTS

Twenty-nine patients with both disorders were found and were compared with 233 patients with idiopathic BPPV. The patients with BPPV associated with Meniere's disease presented the following features, in which they differed from the patients with idiopathic BPPV: 1) a higher percentage of female patients; 2) a longer duration of symptoms; 3) common involvement of the horizontal semicircular canal; 4) a greater incidence of canal paresis; and 5) more therapeutic sessions needed for cure and a higher rate of recurrence.

CONCLUSIONS

The BPPV associated with Meniere's disease differs from idiopathic BPPV in regard to several epidemiological and clinical features, may follow a different course, and responds less effectively to treatment.

Clinical Features of Recurrent or Persistent Benign Paroxysmal Positional Vertigo

Objectives

To identify clinical features and causes of recurrent or persistent benign paroxysmal positional vertigo (BPPV) and to analyze the effectiveness of frequently repeated canalith repositioning procedures (CRPs).

Study Design

Case series with chart review.

Setting

Academic university hospital.

Methods

The authors retrospectively reviewed the clinical records of 120 patients who were diagnosed with BPPV at the Dizziness Clinic in Ajou University Hospital, Korea, between 2004 and 2008. “Persistent” and “recurrent” BPPV were respectively defined as BPPV continuing more than 2 weeks and recurring BPPV in the same canals after at least 2 weeks of a symptom-free interval following previous successful treatments. The authors treated patients with frequently repeated CRPs such as the modified Epley maneuver or a barbecue rotation every 2 or 3 days in the outpatient clinic.

Results

Among 120 patients with BPPV, 93 (77.5%) were typical, 15 (12.5%) were persistent, and 12 (10.0%) were recurrent. Although the most common cause was idiopathic in both recurrent and persistent BPPV, secondary causes, including trauma, were much more common in recurrent and persistent BPPV than in typical BPPV. Typical and recurrent BPPV developed most commonly in the posterior semicircular canals. Persistent BPPV was most commonly detected in the lateral semicircular canals. After frequently repeated CRPs, 91.7% and 86.7% of the patients with recurrent or persistent BPPV, respectively, had resolution of nystagmus and vertigo.

Conclusion

Recurrent and persistent BPPV are not rare diseases and occur with a higher incidence than expected, especially in patients with secondary causes. However, they can be successfully treated with frequently repeated CRPs.

Benign paroxysmal positional vertigo after use of noise-canceling headphones

Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo. We describe a case of a woman presenting acutely with a severe episode of disabling positional vertigo. Although she had no known etiologic risk factors, this attack followed 12 hours of continuously wearing digital noise-canceling headphones. This is the first such reported association between BPPV and the use of this gadget. We also provide a short review of BPPV and speculate on the possible pathogenic mechanisms involved.

Benign paroxysmal positional vertigo following whiplash injury: a myth or a reality?

OBJECTIVE

The aim of the study was to evaluate the true incidence, diagnosis, and treatment of benign paroxysmal positional vertigo (BPPV) arising after whiplash injury and to distinguish this type of posttraumatic vertigo from other types of dizziness complained after trauma.

METHODS

This was a retrospective study comprising patients referred to our center after whiplash injury. The patients were evaluated with neurotologic examination including bedside and instrumental tests. A Dizziness Handicap Inventory evaluating the symptoms of patients was submitted before and after treatment and was evaluated. The BPPV patients were separately evaluated from those with cervicogenic vertigo, and a comparison between our data about idiopathic BPPV was done.

RESULTS

Eighteen patients of whiplash who had BPPV were evaluated. The mean age was 38.2 years. BPPV was the cause of vertigo in 33.9% of total whiplash patients. In 16 cases, the posterior semicircular canal was involved; the lateral semicircular canal was involved in 2 cases. The instrumental neurotologic assessment did not show any alteration of either vestibulospinal reflexes or dynamic ocular movements. Duration of symptoms before treatment ranged from 3 to 26 days. A total of 55.5% of patients had relief from their symptoms after first repositioning maneuver. The Dizziness Handicap Inventory score improved in all patients treated with repositioning maneuvers, but no difference emerged with idiopathic BPPV data.

CONCLUSION

BPPV after whiplash injury could be unveiled with a simple bedside examination of peripheral vestibular system, and a treatment could be done in the same session. The diagnosis of posttraumatic BPPV is not different from the idiopathic form, but the treatment may require more maneuvers to achieve satisfactory results.