1
|
Kim HJ, Kim N, Gil YE, Kim JS. Atypical Benign Paroxysmal Positional Vertigo: Concomitant Cupulolithiasis and Short-Arm Canalolithiasis Involving the Posterior Canal? J Clin Neurol 2024; 20:336-338. [PMID: 38713078 PMCID: PMC11076199 DOI: 10.3988/jcn.2023.0445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/04/2023] [Accepted: 12/30/2023] [Indexed: 05/08/2024] Open
Affiliation(s)
- Hyun-Jae Kim
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Korea
| | - Namyoung Kim
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Korea
| | - Young-Eun Gil
- Department of Neurology, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ji-Soo Kim
- Department of Neurology, Dizziness Center, and Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Neurology, Seoul National University College of Medicine, Seoul, Korea.
| |
Collapse
|
2
|
Kim HJ, Gil YE, Kim JS. Subjective BPPV revisited: identification of positional nystagmus with a new maneuver. J Neurol 2024:10.1007/s00415-024-12347-8. [PMID: 38564054 DOI: 10.1007/s00415-024-12347-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/21/2024] [Accepted: 03/23/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Hyun-Jae Kim
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Young-Eun Gil
- Department of Neurology, College of Medicine, St. Vincent's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji-Soo Kim
- Department of Neurology, Dizziness Center, and Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea.
- Department of Neurology, Seoul National University College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
3
|
Ludwig D, Schubert MC. Case Report: Keep your eyes open! Nystagmus guides atypical BPPV. FRONTIERS IN REHABILITATION SCIENCES 2024; 5:1384151. [PMID: 38606004 PMCID: PMC11006958 DOI: 10.3389/fresc.2024.1384151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 03/14/2024] [Indexed: 04/13/2024]
Abstract
The clinical diagnosis of benign paroxysmal positional vertigo (BPPV) is confirmed from observing the direction, intensity, and duration of nystagmus from unique head positions that advantage gravity to overcome the inertia of otoconia displaced inside the semicircular canals. This case series highlights BPPV with atypical nystagmus presentations relative to the head position. Clinicians should carefully observe symptoms and nystagmus presentations regardless of the testing position and utilize technology and rules of vestibular physiology to enhance their diagnostic acumen.
Collapse
Affiliation(s)
- Daniel Ludwig
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, United States
| | - Michael C. Schubert
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, United States
- Laboratory of Vestibular NeuroAdaptation, Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, MD, United States
| |
Collapse
|
4
|
Garaycochea O, Pérez-Fernández N. Variants of posterior semicircular canal involvement in benign paroxysmal positional vertigo. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2024:S2173-5735(24)00045-0. [PMID: 38438080 DOI: 10.1016/j.otoeng.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/24/2024] [Indexed: 03/06/2024]
Abstract
Benign paroxysmal positional vertigo is the most common cause of peripheral vertigo. It is characterized by short and recurrent episodes of vertigo, trigged by specific head movements that displace otoconia within the semicircular canals. The movement of dislodge otoconia from the utricle cause abnormal positional endolymphatic currents. Primary treatment involves reposition maneuvers aimed at moving the displaced otoconia out the affected canal, therefore correct identification of the affected canal is essential for the diagnosis. The posterior semicircular canal (PSC) is the most frequently affected due to its spatial orientation and the force of gravity. Recent technological advances have allowed for better assessment of positional nystagmus during diagnostic and therapeutic maneuvers, revealing various possible scenarios of PSC involvement. Regarding the PSC, otoconia may be found in different parts of the canal, and not just in the expected location, floating in the long arm of the canal. The understanding of these variants is crucial, as the prognosis and the disease progression differ in such cases. This review aims to describe the six possible variants of PSC involvement described so far.
Collapse
Affiliation(s)
- Octavio Garaycochea
- Departamento de Otorrinolaringología, Hospital Vall d'Hebron, Barcelona, Spain.
| | | |
Collapse
|
5
|
Harrell RG, Hart R, Jen JC, Whitney SL. Surveying physical therapists' understanding of benign paroxysmal positional vertigo. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1228453. [PMID: 37662546 PMCID: PMC10469676 DOI: 10.3389/fresc.2023.1228453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/04/2023] [Indexed: 09/05/2023]
Abstract
Introduction Benign paroxysmal positional vertigo (BPPV) is a common condition with disabling symptoms that is diagnosed and effectively treated at the bedside. Our encounter with patients experiencing prolonged BPPV who may not have received appropriate physical therapy prompted us to explore barriers to the diagnosis and treatment for BPPV among physical therapists, which has not been extensively investigated. We hypothesize that a potential barrier may be a lack of understanding of subtle symptoms of BPPV that deviate from the classical presentation. The gold standard for diagnosing definite BPPV is subjective dizziness or vertigo with nystagmus in response to positional testing. There are variants of BPPV including subjective BPPV (subjective dizziness or vertigo without nystagmus) and vestibular agnosia (nystagmus without subjective dizziness or vertigo) that do not meet the diagnostic criteria for definite BPPV but are equally responsive to the same repositioning maneuvers. The purpose of this project was to survey physical therapists for their understanding of BPPV including subjective BPPV and vestibular agnosia. Methods A panel of experts created a 16-question survey, designed for physical therapists, with three categories: (1), inquiring if they treat persons with BPPV, (2) three clinical vignettes for definite BPPV, subjective BPPV, and BPPV with vestibular agnosia, and (3) demographic information. Data collection occurred at two large physical therapy meetings, one of which was a national professional meeting and the other was a professional continuing medical education course geared towards advancing vestibular rehabilitation skills. Results There were 426 people who completed the survey, 364 of whom treat BPPV in their practice. In the first clinical vignette created to assess the respondents' understanding of definite BPPV, 229 (62%) of respondents would always assess a patient for BPPV based on complaints of a "room spinning" vertigo from head movement. When asked if the complaint was lingering "lightheadedness or feelings of imbalance" from head movement, only 158 (43%) reported they would perform positional testing to reassess. In the BPPV variant vignettes, 187 (51%) identified the patient with subjective BPPV as having BPPV and 305 (85%) identified the patient with vestibular agnosia as having BPPV. Discussion The results of this survey demonstrate gaps in knowledge regarding BPPV across practice settings and experience, with opportunities to bridge these gaps to improve treatment for BPPV.
Collapse
Affiliation(s)
- Regan G. Harrell
- Department of Physical Therapy, The University of Pittsburgh, Pittsburgh, PA, United States
| | - Rebecca Hart
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Joanna C. Jen
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Susan L. Whitney
- Department of Physical Therapy, The University of Pittsburgh, Pittsburgh, PA, United States
| |
Collapse
|
6
|
Ludwig D, Schubert MC. Resolution of atypical posterior semicircular canal BPPV: evidence for putative short-arm location. BMJ Case Rep 2023; 16:e254579. [PMID: 37247949 PMCID: PMC10230912 DOI: 10.1136/bcr-2023-254579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
This case demonstrates the successful identification and treatment of atypical posterior semicircular canal benign paroxysmal positional vertigo (BPPV) based on a unique presentation of positional nystagmus, the resultant nystagmus from repositioning manoeuvers, and restored function of the affected semicircular canal. This case illustrates the importance of completing a comprehensive clinical examination and the value for incorporating the video head impulse test as well as adjusting treatment based on testing and patient response when managing variant cases of BPPV.
Collapse
Affiliation(s)
- Daniel Ludwig
- Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, USA
| | - Michael C Schubert
- Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, USA
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland, USA
| |
Collapse
|
7
|
Murphy OC, Hac NEF, Gold DR. Updates in neuro-otology. Curr Opin Neurol 2023; 36:36-42. [PMID: 36380583 DOI: 10.1097/wco.0000000000001127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE OF REVIEW Recent updates with clinical implications in the field of neuro-otology are reviewed. RECENT FINDINGS Important updates relating to several neuro-otologic disorders have been reported in recent years. For benign positional paroxysmal vertigo (BPPV), we provide updates on the characteristics and features of the short arm variant of posterior canal BPPV. For the acute vestibular syndrome, we report important updates on the use of video-oculography in clinical diagnosis. For autoimmune causes of neuro-otologic symptoms, we describe the clinical and paraclinical features of kelch-like protein 11 encephalitis, a newly-identified antibody associated disorder. For cerebellar ataxia, neuropathy, vestibular areflexia syndrome, we report recent genetic insights into this condition. SUMMARY This review summarizes important recent updates relating to four hot topics in neuro-otology.
Collapse
Affiliation(s)
- Olwen C Murphy
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | |
Collapse
|
8
|
Helminski JO. Case report: Atypical patterns of nystagmus suggest posterior canal cupulolithiasis and short-arm canalithiasis. Front Neurol 2022; 13:982191. [PMID: 36299265 PMCID: PMC9588913 DOI: 10.3389/fneur.2022.982191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 07/26/2022] [Indexed: 12/03/2022] Open
Abstract
Background Atypical posterior canal (PC) positional nystagmus may be due to the changes in cupular response dynamics from cupulolithiasis (cu), canalithiasis of the short arm (ca-sa), or a partial/complete obstruction—jam. Factors that change the dynamics are the position of the head in the pitch plane, individual variability in the location of the PC attachment to the utricle and the position of the cupula within the ampulla, and the location of debris within the short arm and on the cupula. The clinical presentation of PC-BPPV-cu is DBN with torsion towards the contralateral side in the DH positions and SHHP or no nystagmus in the ipsilateral DH position and no nystagmus upon return to sitting from each position. The clinical presentation of PC-BPPV-ca-sa is no nystagmus in the DH position and upbeat nystagmus (UBN) with torsion lateralized to the involved side upon return to sitting from each position. Case description A 68-year-old woman, diagnosed with BPPV, presented with DBN associated with vertigo in both DH positions and without nystagmus or symptoms on sitting up. In the straight head hanging position (SHHP), the findings of a transient burst of UBN with left torsion associated with vertigo suggested ipsicanal conversion from the left PC-BPPV-cu to canalithiasis. Treatment included a modified canalith repositioning procedure (CRP), which resulted in complete resolution. BPPV recurred 17 days later. Clinical presentation of BPPV included no nystagmus/symptoms in both the contralateral DH position and SHHP, DBN in the ipsilateral DH position without symptoms, and UBN with left torsion associated with severe truncal retropulsion and nausea on sitting up from provoking position. The findings suggested the left PC-BPPV-cu-sa and PC-BPPV-ca-sa. Treatment included neck extension, a modified CRP, and demi-Semont before complete resolution. Conclusion An understanding of the biomechanics of the vestibular system is necessary to differentially diagnose atypical PC-BPPV. DH test (DHT) findings suggest that PC-BPPV-cu presents with DBN or no nystagmus in one or two DH positions and sometimes SHHP and without nystagmus or no reversal/reversal of nystagmus on sitting up. The findings suggest PC-BPPV-ca-sa has no nystagmus in DH positions or DBN in the ipsilateral DH position and UBN with torsion lateralized to the involved side on sitting up.
Collapse
|
9
|
Grove CR, Souza WH, Gerend PL, Ryan CA, Schubert MC. Patients’ Experiences with Management of Benign Paroxysmal Positional Vertigo: Insights from the Vestibular Disorders Association Registry. Patient Relat Outcome Meas 2022; 13:157-168. [PMID: 35821793 PMCID: PMC9271286 DOI: 10.2147/prom.s370287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 06/24/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Benign paroxysmal positional vertigo (BPPV) is the most frequently occurring peripheral vestibular disorder. Clinical practice guidelines (CPG) for BPPV exist; however, little is known about how affected patients perceive their condition is being managed. We aimed to leverage registry data to evaluate how adults who report BPPV are managed. Material and Methods We retrospectively analyzed of data from 1,262 adults (58.4 ± 12.6 years old, 81.1% female, 91.1% White) who were enrolled in the Vestibular Disorders Association Registry from 2014 to 2020. The following patient-reported outcomes were analyzed by proportions for those who did and did not report BPPV: symptoms experienced, falls reported, diagnostics undertaken, interventions received (eg, canalith repositioning maneuvers [CRMs], medications), and responses to interventions. Results Of the 1,262 adults included, 26% reported being diagnosed with BPPV. Many adults who reported BPPV (83%) also endorsed receiving additional vestibular diagnoses or may have had atypical BPPV. Those with BPPV underwent magnetic resonance imaging and were prescribed medications more frequently than those without BPPV (76% vs 57% [χ2=36.51, p<0.001] and 85% vs 78% [χ2=5.60, p=0.018], respectively). Falls were experienced by similar proportions of adults with and without BPPV (55% vs 56% [χ2==11.26, p=0.59]). Adults with BPPV received CRMs more often than those without BPPV (86% vs 48%, χ2=127.23, p<0.001). More registrants with BPPV also endorsed benefit from CRMs compared to those without BPPV (51% vs 12% [χ2=105.30, p<0.001]). Discussion In this registry, BPPV was often reported with other vestibular disorders. Healthcare utilization was higher than would be expected with care based on the CPG. The rates of falls in those with and without BPPV are higher than previously reported. Adults with BPPV reported significant differences in how their care is managed and their overall outcomes compared to those without BPPV. Conclusion Patient-reported outcomes provide useful information regarding the lived experience of adults with BPPV.
Collapse
Affiliation(s)
- Colin R Grove
- Department of Otolaryngology - Head and Neck Surgery, Laboratory for Vestibular NeuroAdaptation, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Wagner Henrique Souza
- KITE, Toronto Rehabilitation Institute – University Health Network, Toronto, ON M5G 2A2, Canada
| | | | - Cynthia A Ryan
- Vestibular Disorders Association (VeDA), Portland, OR, 97211, USA
| | - Michael C Schubert
- Department of Otolaryngology - Head and Neck Surgery, Laboratory for Vestibular NeuroAdaptation, Johns Hopkins University, Baltimore, MD, 21205, USA
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD, 21205, USA
- Correspondence: Michael C Schubert, Department of Otolaryngology - Head and Neck Surgery, Johns Hopkins University, 601 N. Caroline Street, 6th Floor, Baltimore, MD, 21205, USA, Tel +1 410 955 7381, Email
| |
Collapse
|