Central Conditions Mimicking Benign Paroxysmal Positional Vertigo: A Case Series

Residual dizziness after BPPV management: exploring pathophysiology and treatment beyond canalith repositioning maneuvers

Despite the high success rate of canalith repositioning maneuvers (CRMs) in the treatment of benign paroxysmal positional vertigo (BPPV), a growing number of patients report residual dizziness symptoms that may last for a significant time. Although the majority of BPPV cases can be explained by canalolithiasis, the etiology is complex. Consideration of the individual patient's history and underlying pathophysiology of BPPV may offer the potential for treatment approaches supplementary to CRMs, as well as a promising alternative for patients in whom CRMs are contraindicated. This article provides a summary of the possible underlying causes of BPPV and residual dizziness, along with suggestions for potential management options that may be considered to relieve the burden of residual symptoms.

Intracranial tumors mimicking benign paroxysmal positional vertigo: A case series

Background

A few intracranial lesions may present only with positional vertigo which are very easy to misdiagnose as benign paroxysmal positional vertigo (BPPV); the clinicians should pay more attention to this disease.

Objectives

To analyze the clinical characteristics of 6 patients with intracranial tumors who only presented with positional vertigo to avoid misdiagnosing the disease.

Material and methods

Six patients with intracranial tumors who only presented with positional vertigo treated in our clinic between May 2015 to May 2019 were reviewed, and the clinical symptoms, features of nystagmus, imaging presentation, and final diagnosis of the patients were evaluated.

Results

All patients presented with positional vertigo and positional nystagmus induced by the changes in head position or posture, including one case with downbeating nystagmus in a positional test, two cases with left-beating nystagmus, one case with apogeotropic nystagmus in a roll test, one case with right-beating nystagmus, and one case with left-beating and upbeating nystagmus. Brain MRI showed the regions of the tumors were in the vermis of the cerebellum, the fourth ventricle, the lateral ventricle, and the cerebellar hemisphere.

Peripheric smell regions in patients with semicircular canal dehiscence: An MRI evaluation

OBJECTIVES

We investigated the peripheric smell regions in patients with semicircular canal dehiscence (SCD) by cranial MRI.

METHODS

In this retrospective study, cranial MRI images of 186 adult patients were included. Group 1 consisted of 83 adult patients with SCD. The control group (Group 2) consisted of 83 healthy subjects without central vertigo. Olfactory bulb (OB) volume and olfactory sulcus (OS) depth were measured in all groups.

RESULTS

In group 1, SCD was detected on the right (33.7%), left (26.5%) sides and bilateral (39.8%). Localization of dehiscence was at superior SC (75.9%), posterior SC (21.7%), lateral SC (1.2%), and posterior + superior SCs (1.2%). OB volumes of the SCD group were significantly lower than the control group bilaterally (p < 0.05). There were no significant differences between OS depths of groups 1 and 2 (p > 0.05). In SCD group, there were positive correlations between OB volumes; OS depths; and OB volumes and OS depths (p < 0.05). In older patients, bilateral OS depth values got lower (p < 0.05). In females, left OB volume values were lower than males (p < 0.05). In right SCD (+) patients, left OS depth values got lower (p < 0.05).

CONCLUSION

We concluded that possible changes in CSF dynamics may cause the development of SCD at thin bone segments; and a decrease in the OB volume. CSF leaks into the perineural sheet of the olfactory bulb (OB) maybe responsible for the decrease in the OB volume. In addition, minor trauma, infection, and inflammation may also be responsible for both coexistences of SCD development and OB volume decrease.

[Vertical downbeat nystagmus in benign paroxysmal positional vertigo]

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

OBJECTIVE

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

Characteristics of assessment and treatment in Benign Paroxysmal Positional Vertigo (BPPV)

QUESTION:

Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of dizziness presenting to specialist vestibular centres and accounts for approximately 20–30% of referrals to these clinics. In spite of the amount of clinical knowledge surrounding its diagnosis and management, the treatment of BPPV remains challenging for even the most experienced clinicians. This study outlines the incidence of BPPV in a specialised vestibular physiotherapy clinics and discusses the various nuances encountered during assessment and treatment of BPPV.

DESIGN:

Observational Study

PARTICIPANTS:

314 patients with various forms of Benign Paroxysmal Positional Vertigo (BPPV)

INTERVENTION:

Canalith repositioning manoeuvres (CRP) for posterior canal (PC) or horizontal canal (HC) BPPV depending on the canal and variant of BPPV.

OUTCOME MEASURES:

Negative Dix-Hallpike (DHP) or Supine roll test (SRT) examination.

RESULTS:

In 91% of cases, PC BPPV was effectively treated in 2 manoeuvres or less. Similarly, 88% of HC BPPV presentations were effectively managed with 2 treatments. Bilateral PC, multiple canal or canal conversions required a greater number of treatments. There was no noticeable difference in treatment outcomes for patients who had nystagmus and symptoms during the Epley manoeuvre (EM) versus those who did not have nystagmus and symptoms throughout the EM. Nineteen percent of patients experienced post treatment down-beating nystagmus (DBN) and vertigo or “otolithic crisis” after the first or even the second consecutive EM.

CONCLUSION:

Based on the data collected, we make several clinical recommendations for assessment and treatment of BPPV. Firstly, repeated testing and treatment of BPPV within the same session is promoted as a safe and effective approach to the management of BPPV with a low risk of canal conversion. Secondly, vertigo and nystagmus throughout the EM is not indicative of treatment success. Thirdly, clinicians must remain vigilant and mindful of the possibility of post treatment otolithic crisis following the treatment of BPPV. This is to ensure patient safety and to prevent possible injurious falls. Our results challenge several clinical assumptions about the assessment and treatment of BPPV including the utility of certain markers of treatment success; hence influencing the current clinical guidelines and clinical practice and paving the way for future studies of the assessment and management of patients with BPPV.