Basophilic deposits on the cupula: preliminary findings describing the problems involved in studies regarding the incidence of basophilic deposits on the cupula

Bilateral Dysfunction of Otolith Pathway in Patients With Unilateral Idiopathic BPPV Detected by ACS-VEMPs

Objective

To observe the functional status of the otolith pathway in patients with unilateral idiopathic benign paroxysmal positional vertigo (BPPV) by combining air-conducted sound elicited cervical vestibular-evoked myogenic potential (ACS-cVEMP) and ocular vestibular-evoked myogenic potential (ACS-oVEMP).

Methods

One hundred and eighty patients with BPPV were recruited for conventional cVEMP and oVEMP tests. The abnormal rates of VEMPs were compared between BPPV patients and control participants.

Results

The abnormal rates of cVEMP and oVEMP in BPPV patients were 46.7% (84/180) and 57.2% (103/180) in affected ears, respectively, and 45.0% (81/180) and 56.7% (102/180) in unaffected ears, respectively; both were significantly higher than the abnormal rates of cVEMP and oVEMP in normal control ears. Compared with normal subjects, the cVEMP response rate was lower in affected and unaffected ears in BPPV patients. The abnormal rates of cVEMP and oVEMP were 48.1% (76/158) and 57.6% (91/158) in patients with posterior semicircular canal BPPV, and 36.4% (8/22) and 54.5% (12/22) in lateral semicircular canal BPPV. There was no significant difference in VEMP abnormalities between posterior semicircular canal BPPV and lateral semicircular canal BPPV.

Conclusion

The prevalence of abnormal cVEMPs and oVEMPs in both affected and unaffected ears of patients with BPPV was significantly higher than that observed in the control group. The pathological mechanism of unilateral idiopathic BPPV may be associated with bilateral degeneration of otolith pathways.

How rare is benign paroxysmal positional vertigo in children? A review of 20 cases and their epidemiology

OBJECTIVE

The clinical features and incidence of benign paroxysmal positional vertigo (BPPV) are not well known in pediatric populations. The aim of this study was to describe the clinical characteristics of pediatric BPPV and to estimate the frequency of pediatric BPPV in the general population.

METHODS

We retrospectively reviewed the medical records of 20 children (6-14 years old) diagnosed with BPPV between 2007 and 2017. The age/sex distribution of BPPV for all ages at our hospital and in the Korean Health Insurance Review and Assessment Service-National Patient Sample (HIRA-NPS) database were compared. The annual incidence and proportion of children with BPPV were calculated.

RESULTS

BPPV occurred 1.86 times more frequently in girls than in boys. Nine children (45%) had associated comorbidities, such as inner ear disorders and recent head trauma. The posterior and lateral semicircular canals were most commonly involved (n = 9 for each), and recurrence was observed in two patients (10%). Children younger than 15 years accounted for approximately 1% of all BPPV cases. The annual incidence of BPPV was 171.5/100,000 for all ages and 9.5/100,000 in the pediatric population.

CONCLUSIONS

Our findings suggest that pediatric BPPV is a relatively uncommon cause of vertigo in children and that the rates of related illness and recurrence are high.

Benign Paroxysmal Positional Vertigo (BPPV) in Children and Adolescents: Clinical Features and Response to Therapy in 110 Pediatric Patients

OBJECTIVE

This study aimed to characterize the clinical features and outcomes of benign paroxysmal positional vertigo (BPPV) in the pediatric population.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary care center.

PATIENTS

One hundred ten patients, aged 5 to 19 years old, diagnosed with BPPV.

MAIN OUTCOME MEASURES

Patient demographics, comorbidities, canal involvement, response to treatment, and incidence of recurrence.

RESULTS

BPPV was diagnosed in 19.8% of patients seen for dizziness during the study period. Patient age ranged 5 to 19 years old (mean =13.4 ± 3.4 yr). Female:male ratio was 3:2. The most prevalent comorbidities were concussion (n = 42, 38.2%) and migraine disorders (n = 33, 30.0%). Average time to diagnosis from symptom onset was 178.2 ± 190.8 days. The posterior canal was most frequently affected (n = 80, 72.7%), followed by the lateral canal (n = 37, 33.6%) and superior canal (n = 21, 19.1%), and 36.4% (n = 40) of patients had multiple canals affected. Treatment requiring more than or equal to five maneuvers to achieve resolution was observed in 11.8% of cases (n = 13). Recurrence was observed in 18.2% of cases. A logistic regression analysis demonstrated that patients with vestibular migraine or benign paroxysmal vertigo of childhood had five times higher odds of recurrence of BPPV, p = 0.003, 95% [1.735, 15.342], than those who did not have either.

CONCLUSIONS

BPPV is a relatively common cause of dizziness in the pediatric population. Children and adolescents with BPPV can be successfully treated with repositioning maneuvers but may be at risk for treatment resistance and recurrence. Increased awareness of BPPV in pediatric patients may reduce delays in identification and treatment.

Spectrum of Middle and Inner Ear Abnormalities in Infants With Congenital Heart Defects

Objective:

To evaluate temporal bone histopathology in infants with congenital heart defects (CHD).

Study Design and Setting:

A retrospective review of our temporal bone collection was conducted to identify temporal bones acquired from infants with CHD. Subjects were divided into nonsyndromic and syndromic CHD groups. The presence of temporal bone abnormalities and the incidence of abnormalities that may result in hearing impairment were determined.

Results:

Thirty-eight temporal bones obtained from 16 infants with nonsyndromic CHD and 4 with syndromic CHD were evaluated. Nonsyndromic CHD cases had abnormalities such as a mesenchymal remnant, malformed stapes, persistent stapedial artery, shallow round window, dehiscent facial nerve canal, short cochlea, strial basophilic deposits, deformity of the spiral ligament, bulging Reissner's membrane, hypoplastic lateral semicircular canal, and cupular deposits. Syndromic CHD cases had abnormalities including narrow round window niche, facial canal dehiscence, strial basophilic deposits and cysts, and outer hair cell loss. Middle and inner ear abnormalities that may impair hearing were observed in 6 subjects with nonsyndromic CHD and in 1 subject with syndromic CHD.

Conclusions:

A wide variety of temporal bone defects were documented in infants with CHD. Congenital middle and inner ear abnormalities should be anticipated in the hearing assessment and otologic surgery of infants with CHD.

Diagnostic, Pathophysiologic, and Therapeutic Aspects of Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo is the most common peripheral vestibular disorder. It can be defined as transient vertigo induced by a rapid head position change, associated with a characteristic paroxysmal positional nystagmus. Canalolithiasis of the posterior semicircular canal is considered the most convincing theory of its pathogenesis and the development of appropriate therapeutic maneuvers resulted in its effective treatment. However, involvement of the horizontal or the anterior canal has been found in a significant rate and the recognition and treatment of these variants completed the clinical picture of the disease. This paper describes the advances in understanding how this disease is generated and discusses the current therapeutic modalities.

Prevalence and Characteristics of Positional Nystagmus in Normal Subjects

OBJECTIVE

In clinical practice, patients are often referred due to a finding of positional nystagmus that does not always appear to correlate with clinical symptoms of benign paroxysmal positional vertigo. To know when to consider nystagmus to be of clinical relevance, it is necessary to know the prevalence and characteristics of positional nystagmus in a healthy population.

STUDY DESIGN

Case series of 75 healthy subjects.

SETTING

Two tertiary referral centers in Norway.

SUBJECTS AND METHODS

Seventy-five adult subjects aged 40 ± 13 years (mean ± SD; range, 21-87) without a history of vertigo or balance disorder were included from 2013 to 2015. The subjects underwent 6 different standardized positional tests in a repositioning chair. Videonystagmography was used to record eye movements. Of 1350 recordings, 1329 were included and analyzed.

RESULTS

Positional nystagmus was detected in 88% of the subjects. The most common finding was nystagmus in the Dix-Hallpike position, which occurred in 55% of the subjects. The 95th percentile of the maximum slow-phase velocity for each subject was found to be 5.06° per second (n = 54) in the horizontal plane and 6.48° per second (n = 48) in the vertical plane.

CONCLUSION

Positional nystagmus is a common finding in normal subjects and occurred in 88% of the healthy subjects in the present study. Horizontal direction-changing apogeotropic or geotropic nystagmus may occur in asymptomatic subjects. However, nystagmus that is of the paroxysmal type or has a slow-phase velocity greater than approximately 5° per second in the horizontal plane or 6.5° per second in the vertical plane should be considered outside the 95th percentile.

Potential cause of positional vertigo in Ménière's disease

OBJECTIVES

To compare the incidence of deposits in the semicircular canals between the temporal bones with Ménière's disease and normal controls and to investigate the relationship between the incidence of deposits and the symptoms of positional vertigo, often seen in patients with Ménière's disease.

STUDY DESIGN

Retrospective histopathologic human temporal bone study.

METHODS

Twenty-two temporal bones from 11 patients with bilateral Ménière's disease, 28 from 14 with unilateral and 50 age-matched normal temporal bones from 30 individuals were histopathologically examined. Medical records were reviewed for clinical history of positional vertigo and duration of disease.

RESULTS

Significant differences were found in the incidence of cupular and free-floating deposits in the posterior semicircular canals between temporal bones with and without Ménière's disease. The incidence of free-floating deposits in the lateral semicircular canals was significantly higher in cases with unilateral Ménière's disease compared with controls. The incidence of these deposits was associated with the duration of disease rather than with aging. All 5 patients with positional vertigo (3 of 11 patients of bilateral Ménière's disease and 2 of 14 of unilateral) had free-floating deposits in at least 1 semicircular canal.

CONCLUSION

Our findings suggest a possible causative relationship between cupular and free-floating deposits in the semicircular canals and the symptom of positional vertigo in patients with Ménière's disease.

Etiology of vertigo in children

OBJECTIVE

To detect the most common causes of vertigo in children.

METHODS

Fifty-four children (20 boys and 34 girls) aged 3-16 years, who presented with vertigo attacks during a 3-year period, were studied. A detailed medical history for vestibular symptoms and migraine was obtained from our patients or their parents. All patients underwent otolaryngologic, ophthalmologic and neurologic clinical evaluation. A detailed laboratory examination, including serologic tests for viral infections, was also obtained. Additionally, a complete audiological and neurotologic evaluation was performed. Computed tomography (CT) scans and magnetic resonance imaging (MRI) were obtained in selected cases.

RESULTS

Viral infections, benign paroxysmal vertigo of childhood and migraine were the most common causes of vertigo accounting for approximately 65% of our patients. Otitis media, head trauma, benign paroxysmal positional vertigo, Meniere's disease and brain tumor were less common causes of vertigo.

CONCLUSIONS

A peripheral type of vertigo was found in most cases. Diagnostic approach in vertigo in children should include a detailed history and clinical examination in conjunction with a test battery of audiological and neurotologic tests. When a central cause of vertigo is suspected an MRI or CT scan should be ordered.

[Histomorphological study of experimentally induced canalolithiasis]

Free otoconia in the posterior semicircular canal (pSCC) are regarded as the main reason for benign paroxysmal positional vertigo. We investigated the distribution of otoconia in the membranous labyrinth of guinea pigs (n = 34) after a defined rotatory/angular kinetic acceleration. The angular kinetic energy of the rotatory experiment produced a dislocation of the otoconia and sometimes of the complete gelatinous otolithic membrane of the utricular and saccular macula. The otoconia could be observed in all three semicircular canals but predominated in the dark cell areas of the utricular side of the lateral SCC. A total obstruction of the semicircular canal could never be seen. Close to the lateral crista, perilymphatic hemorrhage could frequently be observed. The saccular otoconia were located in the amalgamation between endolymphatic membrane and saccule. The results of this histological study can form the basis for different theories about the genesis of canalolithiasis and cupulolithiasis and the vertigo which accompanies them.

Occurrence of semicircular canal involvement in benign paroxysmal positional vertigo

OBJECTIVES

To study the occurrence of each variant of benign paroxysmal positional vertigo (BPVV) and to present some specific clinical features and the results of their treatment by appropriate repositioning maneuvers.

STUDY DESIGN

A retrospective review of the records of patients with BPPV.

SETTING

Neurotology clinic of the ear, nose, and throat department of a general hospital.

PATIENTS

One hundred twenty-two patients were included in the study, 54 male and 68 female, mean ages 61.8 and 59.6 years, respectively, ranging in age from 25 years to 86 years and with symptoms lasting for an average of 124 days. The diagnosis of each type of BPPV was based on the history of the patients and on the positive results of the appropriate provoking maneuver.

METHODS

From all the patients, a comprehensive history was obtained, followed by clinical examination of the ears, nose, and throat and a complete audiologic and neurotologic examination, including electronystagmography. All patients were treated with an appropriate repositioning maneuver, depending on the type of BPPV.

RESULTS

Of 122 patients, 110 had posterior canal involvement, 10 had horizontal canal involvement, and only 2 had the anterior canal variant. The canalith repositioning procedure was immediately successful in 106 patients and in 8 more patients proved successful after its repetition in a second session, resulting in a total success rate of 93.4%.

CONCLUSIONS

All the BPPV variants shared the same clinical and demographic characteristics and responded equally well to treatment. However, differential diagnosis was necessary to apply the appropriate canalith repositioning procedure. Although data from clinical and histologic studies do not fully account for the observed relative occurrence of each variant of BPPV, a satisfactory explanation may be provided by the anatomic location of each semicircular canal and additionally by self-treatment of most cases of the horizontal and the anterior canal variety.

The incidence and distribution of cupular deposits in the pediatric vestibular labyrinth

OBJECTIVES

Deposits of basophilic material on the cupulae of the semicircular ducts have been described in adult human temporal bones, and such deposits have been implicated in the clinical phenomenon of benign paroxysmal positional vertigo (BPPV). Although relatively rare, BPPV has been reported to occur in children. The goal of this study was to evaluate the occurrence of cupular deposits in pediatric material.

STUDY DESIGN

Basic science, two-center histopathologic temporal bone study.

METHODS

We examined 186 temporal bones from 121 individuals between the ages of newborn and 10 years. The average age was 14.7 months. All temporal bones were acquired at autopsy, embedded in celloidin, and sectioned for light microscopic study. The cupulae of the semicircular ducts were identified and any deposits found were graded according to their size and position on the cupula.

RESULTS

A total of 276 cupulae were identified, and in 35 (12.7%) of these a basophilic deposit was found. In many cases the deposits contained recognizable otoconial crystals. Most deposits were small and they were almost equally distributed between the three semicircular ducts. However, the lateral and posterior cupulae were somewhat more involved than the superior cupula. Our data showed that cupular deposits are less frequently found in the pediatric labyrinth, compared with adults as reported in previous studies.

CONCLUSIONS

The lower occurrence in children versus adults suggests that the deposits may be a phenomenon of the aging vestibular labyrinth.

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo is a common disorder of the inner ear that should be suspected in all patients with a history of positionally provoked vertigo. The condition appears to be caused by free-floating debris in the posterior semicircular canal. The diagnosis is confirmed by eliciting characteristic symptoms and signs during the Dix-Hallpike test. Although benign paroxysmal positional vertigo is usually a self-limited disorder, treatment with a specific bedside maneuver is effective and can provide the patient immediate and long-lasting relief. Although many patients with positionally provoked vertigo have typical benign paroxysmal positional vertigo, physicians should be aware of nonbenign variants.

Anatomical and theoretical observations on otolith repositioning for benign paroxysmal positional vertigo

OBJECTIVE

To determine if there is an anatomic basis for the assumption that loose, "rogue" otoliths presumed to arise from the utricular macula and theorized to cause benign paroxysmal positional vertigo (BPPV) by impinging on semicircular canal ampullae could be returned to their original site by a series of changes in the position of the head called particle repositioning maneuvers (PRMs). Further, if such otolith movement were possible, once they were replaced into the utricle, would they adhere to the utricular macula?

STUDY DESIGN

Kodachrome photographs of 2-mm-thick macrosections of human temporal bones were available for evaluation. The bones were sectioned in horizontal, coronal, and sagittal planes. Rice grains were placed on the photographs of the cross-sections to demonstrate the possible paths taken by loose otoliths under the influence of gravity in different positions of the head.

RESULTS

A study of cross-sections of the temporal bone shows that loose macular otoliths after PRMs would tend to fall into the lumen of the utricle. Once the patient assumes the erect position, however, repositioned otoliths would tend to fall into the near or utriculopetal side of the cupula of the posterior semicircular canal, which opens directly into the inferior portion of the utricle, and could cause labyrinth stimulation and BPPV by the same mechanism of misplaced otoliths on the opposite or far side of the cupula. Loose otoliths in the utricle could also stimulate the horizontal ampullae.

CONCLUSIONS

PRMs do not remove or fix otoliths in any specific site in the labyrinth. Repositioning of loose otoliths onto the original site in the macula of the utricle, which lies superiorly in the vestibule, could not be accomplished by any of the repositioning maneuvers. If otoliths were to be repositioned on the utricular macula, there is no evidence that the otoliths would adhere to the macula when the patient assumes the erect position. The good results obtained by physiotherapeutic procedures suggest that some other mechanism than repositioning of otoliths is responsible for the relief of BPPV.