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Strupp ML, Zwergal A, Goldschagg N. [The six most frequent peripheral vestibular syndromes]. Laryngorhinootologie 2024; 103:196-206. [PMID: 38134907 DOI: 10.1055/a-2144-3801] [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: 12/24/2023]
Abstract
Three forms of peripheral vestibular disorders, each with its typical symptoms and clinical signs, can be differentiated functionally, anatomically and pathophysiologically: 1. inadequate unilateral paroxysmal stimulation or rarely inhibition of the peripheral vestibular system, e. g., BPPV, Menière's disease, vestibular paroxysmia or syndrome of the third mobile windows; 2. acute unilateral vestibulopathy leading to an acute vestibular tone imbalance manifesting as an acute peripheral vestibular syndrome; and 3. loss or impairment of function of the vestibular nerve and/or labyrinth: bilateral vestibulopathy. For all of these diseases, current diagnostic criteria by the Bárány-Society are available with a high clinical and scientific impact, also for clinical trials. The treatment depends on the underlying disease. It basically consists of 5 principles: 1. Explaining the symptoms and signs, pathophysiology, aetiology and treatment options to the patient; this is important for compliance, adherence and persistence. 2. Physical therapy: A) For BPPV specific liberatory maneuvers, depending on canal involved. Posterior canal: The new SémontPLUS maneuver is superior to the regular Sémont and Epley maneuvers; horizontal canal: the modified roll-maneuver; anterior canal the modified Yacovino-maneuver; 3. Symptomatic or causative drug therapy. There is still a deficit of placebo-controlled clinical trials so that the level of evidence for pharmacotherapy is most often low. 4. Surgery, mainly for the syndrome of the third mobile windows. 5. Psychotherapeutic measures for secondary functional dizziness.
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Affiliation(s)
- Michael Leo Strupp
- Neurologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, München, Germany
- Deutsches Schwindel- und Gleichgewichtszentrum, DSGZ, Ludwig-Maximilians-Universität München, München, Germany
| | - Andreas Zwergal
- Neurologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, München, Germany
- Deutsches Schwindel- und Gleichgewichtszentrum, DSGZ, Ludwig-Maximilians-Universität München, München, Germany
| | - Nicolina Goldschagg
- Neurologische Klinik und Poliklinik, Ludwig-Maximilians-Universität München, München, Germany
- Deutsches Schwindel- und Gleichgewichtszentrum, DSGZ, Ludwig-Maximilians-Universität München, München, Germany
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2
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Chen Z, Guo Q, Huang S, Li L, Wu F, Liu Z, Li Z, Chen T, Song G, Xu S, Chen J, Hou Y. Overcoming adaptive resistance in AML by synergistically targeting FOXO3A-GNG7-mTOR axis with FOXO3A inhibitor Gardenoside and rapamycin. Genes Dis 2024; 11:397-412. [PMID: 37588187 PMCID: PMC10425752 DOI: 10.1016/j.gendis.2023.01.002] [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: 11/04/2022] [Accepted: 01/02/2023] [Indexed: 01/26/2023] Open
Abstract
Therapeutic targeting FOXO3A (a forkhead transcription factor) represents a promising strategy to suppress acute myeloid leukemia (AML). However, the effective inhibitors that target FOXO3A are lacking and the adaptive response signaling weakens the cytotoxic effect of FOXO3A depletion on AML cells. Here, we show that FOXO3A deficiency induces a compensatory response involved in the reactive activation of mTOR that leads to signaling rebound and adaptive resistance. Mitochondrial metabolism acts downstream of mTOR to provoke activation of JNK/c-JUN via reactive oxygen species (ROS). At the molecular level, FOXO3A directly binds to the promoter of G protein gamma subunit 7 (GNG7) and preserves its expression, while GNG7 interacts with mTOR and restricts phosphorylated activation of mTOR. Consequently, combinatorial inhibition of FOXO3A and mTOR show a synergistic cytotoxic effect on AML cells and prolongs survival in a mouse model of AML. Through a structure-based virtual screening, we report one potent small-molecule FOXO3A inhibitor (Gardenoside) that exhibits a strong effect of anti-FOXO3A DNA binding. Gardenoside synergizes with rapamycin to substantially reduce tumor burden and extend survival in AML patient-derived xenograft model. These results demonstrate that mTOR can mediate adaptive resistance to FOXO3A inhibition and validate a combinatorial approach for treating AML.
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Affiliation(s)
- Zhe Chen
- Department of Hematology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
- Institute of Life Sciences, Chongqing Medical University, Chongqing 400016, China
| | - Qian Guo
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400044, China
| | - Shichen Huang
- Chongqing Foreign Language School, Chongqing 400039, China
| | - Lei Li
- Department of Hematology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Feng Wu
- Institute of Life Sciences, Chongqing Medical University, Chongqing 400016, China
| | - Zhilong Liu
- Department of Hematology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Zhigang Li
- Institute of Life Sciences, Chongqing Medical University, Chongqing 400016, China
| | - Tao Chen
- Department of Hematology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Guanbin Song
- Key Laboratory of Biorheological Science and Technology, Ministry of Education, College of Bioengineering, Chongqing University, Chongqing 400044, China
| | - Shuangnian Xu
- Department of Hematology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Jieping Chen
- Department of Hematology, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Yu Hou
- Institute of Life Sciences, Chongqing Medical University, Chongqing 400016, China
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Strupp M, Mandala M, Vinck AS, Van Breda L, Salerni L, Gerb J, Bayer O, Mavrodiev V, Goldschagg N. The Semont-Plus Maneuver or the Epley Maneuver in Posterior Canal Benign Paroxysmal Positional Vertigo: A Randomized Clinical Study. JAMA Neurol 2023; 80:798-804. [PMID: 37358870 PMCID: PMC10425825 DOI: 10.1001/jamaneurol.2023.1408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/18/2023] [Indexed: 06/27/2023]
Abstract
Importance Questions remain concerning treatment efficacy for the common condition of benign paroxysmal positional vertigo (BPPV). Objective To compare the effectiveness of the Semont-plus maneuver (SM-plus) and the Epley maneuver (EM) for treatment of posterior canal benign paroxysmal positional vertigo (pcBPPV) canalolithiasis. Design, Setting, and Participants This prospective randomized clinical trial was performed at 3 national referral centers (in Munich, Germany; Siena, Italy; and Bruges, Belgium) over 2 years, with a follow-up to 4 weeks after the initial examination. Recruitment took place from June 1, 2020, until March 10, 2022. Patients were selected randomly during routine outpatient care after being referred to 1 of the 3 centers. Two hundred fifty-three patients were assessed for eligibility. After consideration of the exclusion criteria as well as informed consent, 56 patients were excluded and 2 declined to participate, with 195 participants included in the final analysis. The analysis was prespecified and per-protocol. Interventions After being randomized to the SM-plus or the EM group, patients received 1 initial maneuver from a physician, then subsequently performed self-maneuvers at home 3 times in the morning, 3 times at noon, and 3 times in the evening. Main Outcome and Measures Patients had to document whether they could provoke positional vertigo every morning. The primary end point was the number of days until no positional vertigo could be induced on 3 consecutive mornings. The secondary end point was the effect of the single maneuver performed by the physician. Results Of the 195 participants included in the analysis, the mean (SD) age was 62.6 (13.9) years, and 125 (64.1%) were women. The mean (SD) time until no positional vertigo attacks could be induced in the SM-plus group was 2.0 (1.6) days (median, 1 [range, 1-8] day; 95% CI, 1.64-2.28 days); in the EM group, 3.3 (3.6) days (median, 2 [range, 1-20] days; 95% CI, 2.62-4.06 days) (P = .01; α = .05, 2-tailed Mann-Whitney test). For the secondary end point (effect of a single maneuver), no significant difference was detected (67 of 98 [68.4%] vs 61 of 97 [62.9%]; P = .42; α = .05). No serious adverse event was detected with both maneuvers. Nineteen patients (19.6%) in the EM group and 24 (24.5%) in the SM-plus group experienced relevant nausea. Conclusions and Relevance The SM-plus self-maneuver is superior to the EM self-maneuver in terms of the number of days until recovery in pcBPPV. Trial Registration ClinicalTrials.gov Identifier: NCT05853328.
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Affiliation(s)
- Michael Strupp
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
- German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany
| | - Marco Mandala
- Department of ENT (Ear, Nose, and Throat), University of Siena, Siena, Italy
| | | | - Laure Van Breda
- Department of ENT, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium
| | - Lorenzo Salerni
- Department of ENT (Ear, Nose, and Throat), University of Siena, Siena, Italy
| | - Johannes Gerb
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
- German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany
| | - Otmar Bayer
- German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany
- ReliaTec GmbH, Garching, Germany
| | - Vergil Mavrodiev
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
- German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany
| | - Nicolina Goldschagg
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
- German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany
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Jiang Y, Liu J, Zhang W, Xiang G, Chen Y, He C, Shen H, Gong J, Bian Y. A low-frequency acceleration sensor inspired by saccule in human vestibule. THE REVIEW OF SCIENTIFIC INSTRUMENTS 2023; 94:025005. [PMID: 36859047 DOI: 10.1063/5.0126150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 01/13/2023] [Indexed: 06/18/2023]
Abstract
A human vestibular system is a group of devices in the inner ear that govern the balancing movement of the head, in which the saccule is responsible for sensing gravity accelerations. Imitating the sensing principle and structure of the Sensory Hair (SH) cell in the saccule, a Bionic Sensory Hair (BSH) was developed, and 9 BSH arrays were arranged in the bionic macular at the bottom of the spherical shell to prepare a Bionic Saccule (BS). Based on the piezoelectric equation, the electromechanical theoretical models of the BSH cantilever and BS were deduced. They were subjected to impact oscillations using an exciter, and their output charges were analyzed to check their sensing ability. The results showed that BSH could sense its bending deflection, and the BS could sense its position change in the sagittal plane and in space. They exhibited a sensitivity of 1.6104 Pc s2/m and a fast response and similar sensing principles and low resonance frequency to those of the human saccule. The BS is expected to be used in the field of robotics and clinical disease diagnosis as a part of the artificial vestibular system in the future.
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Affiliation(s)
- Yani Jiang
- College of Mechanical Engineering, Yangzhou University, No. 196 West Huayang Road, Yangzhou, China
| | - Jialong Liu
- College of Mechanical Engineering, Yangzhou University, No. 196 West Huayang Road, Yangzhou, China
| | - Wenxuan Zhang
- College of Mechanical Engineering, Yangzhou University, No. 196 West Huayang Road, Yangzhou, China
| | - Guangcheng Xiang
- College of Mechanical Engineering, Yangzhou University, No. 196 West Huayang Road, Yangzhou, China
| | - Yuhang Chen
- College of Mechanical Engineering, Yangzhou University, No. 196 West Huayang Road, Yangzhou, China
| | - Can He
- College of Mechanical Engineering, Yangzhou University, No. 196 West Huayang Road, Yangzhou, China
| | - Hui Shen
- College of Mechanical and Electrical Engineering, Qingdao University, No. 308 Ningxia Road, Qingdao, China
| | - Junjie Gong
- College of Mechanical Engineering, Yangzhou University, No. 196 West Huayang Road, Yangzhou, China
| | - Yixiang Bian
- College of Mechanical Engineering, Yangzhou University, No. 196 West Huayang Road, Yangzhou, China
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Bian Y, Lu S, Wang Z, Qin Y, Li J, Guo G, Gong J, Jiang Y. Study the biomechanical performance of the membranous semicircular canal based on bionic models. Heliyon 2022; 8:e09480. [PMID: 35647361 PMCID: PMC9136265 DOI: 10.1016/j.heliyon.2022.e09480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 02/13/2022] [Accepted: 05/13/2022] [Indexed: 11/16/2022] Open
Abstract
A BA (bionic ampulla) was designed and fabricated using an SMPF (Symmetric electrodes Metal core PVDF Fiber) sensor, which could imitate the sensory hair cells to sense the deformation of the cupula of the BA. Based on the BA, a bionic semicircular canal with membrane semicircular canal (MBSC) and a bionic semicircular canal without membrane semicircular canal (NBSC) were designed and fabricated. The biomechanical models of the MBSC and NBSC were established. The biomechanical models were verified through the perception experiments of the MBSC and the NBSC. The results showed that the SMPF could sense the deformation of the cupula. The MBSC and NBSC could sense the angular velocity and accelerations. What's more, it was speculated that in a human body, the endolymph probably had a function of liquid mass while the membranous semicircular canal and the cupula had a function similar to a spring in the human semicircular canal.
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Affiliation(s)
- Yixiang Bian
- School of Mechanical Engineering, Yangzhou University, Yangzhou 225127, China
| | - Shien Lu
- School of Mechanical Engineering, Yangzhou University, Yangzhou 225127, China
| | - Zhi Wang
- School of Mechanical Engineering, Yangzhou University, Yangzhou 225127, China
| | - Yongbin Qin
- School of Mechanical Engineering, Yangzhou University, Yangzhou 225127, China
| | - Jialing Li
- School of Mechanical Engineering, Yangzhou University, Yangzhou 225127, China
| | - Guangming Guo
- School of Mechanical Engineering, Yangzhou University, Yangzhou 225127, China
| | - Junjie Gong
- School of Mechanical Engineering, Yangzhou University, Yangzhou 225127, China
| | - Yani Jiang
- School of Mechanical Engineering, Yangzhou University, Yangzhou 225127, China
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Study on the Perception Mechanism of Utricles Based on Bionic Models. Biomimetics (Basel) 2022; 7:biomimetics7010028. [PMID: 35323185 PMCID: PMC8945493 DOI: 10.3390/biomimetics7010028] [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: 01/21/2022] [Revised: 02/22/2022] [Accepted: 02/22/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The relationship between utricle diseases and structural lesions is not very clear in the clinic due to the complexity and delicacy of the utricle structure. Therefore, it is necessary to study the perception mechanism of the utricle. Methods: Imitating the sensory cells in the macula of the utricle, a symmetrical metal core PVDF fiber (SMPF) was designed as a bionic hair sensor to fabricate a bionic macula (BM), a bionic macula with sand (BMS) and a bionic utricle (BU). Then experiments were carried out on them. Results: This indicated the SMPF sensor can sense its bending deformation, which was similar to the sensory cell. The amplitude of the output charges of the SMPF in BMS and BU were significantly improved. The SMPF, whose electrode boundary was perpendicular to the impact direction, exhibited the largest output charges. Conclusion: The presence of otoliths and endolymph can improve the sensing ability of the utricle. The human brain can judge the direction of head linear accelerations based on the location of the sensory cell in the macula that produces the largest nerve signals. This provides a possibility of studying utricle abnormal functions in vitro in the future.
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Bhandari A, Bhandari R, Kingma H, Strupp M. Diagnostic and Therapeutic Maneuvers for Anterior Canal BPPV Canalithiasis: Three-Dimensional Simulations. Front Neurol 2021; 12:740599. [PMID: 34630309 PMCID: PMC8497794 DOI: 10.3389/fneur.2021.740599] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 08/16/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Objectives: Anterior canal BPPV is a rare BPPV variant. Various diagnostic and therapeutic maneuvers have been described for its management. The aim of this study was to use three-dimensional simulation models to visualize otoconial debris movement within the anterior canal during diagnostic tests and different liberatory maneuvers. This can help to optimize existing treatment maneuvers and help in the development of better management protocols. Methods: Based on reconstructed MRI images and fluid dynamics, a 3D dynamic simulation model (as a function of time) was developed and applied. Simulations of the supine head-hanging test for diagnosis of ac-BPPV were studied. Three repositioning maneuvers were simulated: 1) the Yacovino maneuver and its modifications, 2) the reverse Epley maneuver and 3) the short canal repositioning (CRP) maneuver. Results: The simulation showed that the supine head-hanging test is a good test for diagnosis of ac-BPPV affecting both labyrinths and demonstrated why there is no inversion of nystagmus on sitting up. The Yacovino maneuver was seen to be an effective treatment option for ac-BPPV without having to determine the side involved. However, simulations showed that the classical Yacovino maneuver carried a risk of canal switch to the posterior canal. To overcome this risk, a modified Yacovino maneuver is suggested. The reverse Epley maneuver was not an effective treatment. Short CRP is useful in ac-BPPV treatment; however, it requires determination of side of involvement. Conclusion: The 3D simulator of the movement of the otoconial debris presented here can be used to test the mechanism of action and the theoretical efficacy of existing diagnostic tests and maneuvers as well as to develop new treatment maneuvers to optimize BPPV treatment.
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Affiliation(s)
| | | | - Herman Kingma
- Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Centre, Maastricht, Netherlands.,Faculty of Physics, Tomsk State University, Tomsk, Russia.,Department of ENT, Aalborg University, Aalborg, Denmark
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Ludwig Maximilian University of Munich, Munich, Germany
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Bhandari A, Bhandari R, Kingma H, Zuma E Maia F, Strupp M. Three-dimensional simulations of six treatment maneuvers for horizontal canal benign paroxysmal positional vertigo canalithiasis. Eur J Neurol 2021; 28:4178-4183. [PMID: 34339551 DOI: 10.1111/ene.15044] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Horizontal canal benign paroxysmal positional vertigo (BPPV) is the second most common variant of BPPV after posterior canal BPPV. Various liberatory maneuvers are recommended for the treatment of horizontal canal BPPV canalithiasis (hc-BPPV-ca). The aim of this study was to show how three-dimensional (3D) dynamic simulation models visualize the movement of the clot of otoconia within the canal for a better understanding of the theoretical efficacy. METHODS Based on reconstructed magnetic resonance imaging and fluid dynamics, a 3D dynamic simulation model (as a function of time) was developed and applied. Thereby, six treatment maneuvers for hc-BPPV-ca were simulated: two types of the roll maneuver (the original 270° and the modified 360°) as well as two Gufoni and Zuma maneuvers (for geotropic and apogeotropic nystagmus). RESULTS The simulations showed that the 360° roll maneuver and Zuma maneuver are effective treatment options for hc-BPPV-ca for debris in all locations within the canal. However, the original 270° roll maneuver will not be effective if the clot is in the ampullary arm of the horizontal canal. The Gufoni maneuver for geotropic hc-BPPV-ca is effective, whereas for apogeotropic hc-BPPV-ca there is a risk of treatment failure due to insufficient repositioning of the debris. CONCLUSIONS The 3D simulations for movement of the otoconia clots can be used to test the mechanism of action and the theoretical efficacy of existing maneuvers for the different BPPV variants. For hc-BPPV-ca, the modified 360° roll maneuver and Zuma maneuver are theoretically efficient for all subtypes, whereas Gufoni maneuver is effective for geotropic nystagmus only.
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Affiliation(s)
| | | | - Herman Kingma
- Department of Ear Nose Throat, Maastricht University, Maastricht, Netherlands.,Faculty of Physics, Tomsk State National Research University, Tomsk, Russia.,Department of Ear Nose Throat, Aalborg University, Aalborg, Denmark
| | - Francisco Zuma E Maia
- Department of Otorhinolaryngology and Instituto de Cerebro, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Hospital of Ludwig Maximilian University of Munich, Munich, Germany
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Strupp M, Goldschagg N, Vinck AS, Bayer O, Vandenbroeck S, Salerni L, Hennig A, Obrist D, Mandalà M. BPPV: Comparison of the SémontPLUS With the Sémont Maneuver: A Prospective Randomized Trial. Front Neurol 2021; 12:652573. [PMID: 33935951 PMCID: PMC8079727 DOI: 10.3389/fneur.2021.652573] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/04/2021] [Indexed: 11/23/2022] Open
Abstract
Objective: To compare the efficacy of the Sémont maneuver (SM) with the new “SémontPLUS maneuver” (SM+) in patients with posterior canal BPPV canalolithiasis (pcBPPVcan). Methods and Patients: In a prospective trinational (Germany, Italy, and Belgium) randomized trial, patients with pcBPPVcan were randomly assigned to SM or SM+; SM+ means overextension of the head by 60+° below earth horizontal line during the movement of the patient toward the affected side. The first maneuver was done by the physician, and the subsequent maneuvers by the patients 9 times/day on their own. Each morning the patient documented whether vertigo could be induced. The primary endpoints were: “How long (in days) does it take until no attacks can be induced?” and “What is the efficacy of a single SM/SM+?” Results: In the 194 patients analyzed (96 SM, 98 SM+), it took 2 days (median, range 1–21 days, mean 3.6 days) for recovery with SM and 1 day (median, range 1-8 days, mean 1.8 days) with SM+ (p = 0.001, Mann-Whitney U-test). There was no difference in the second primary endpoint (chi2-test, p = 0.39). Interpretation: This prospective trial shows that SM+ is more effective than SM when repeated therapeutic maneuvers are performed but not when a single maneuver is performed. It also supports the hypothesis of the biophysical model: overextension of the head during step 2 brings the clot of otoconia beyond the vertex of the canal, which increases the effectivity. Classification of Evidence: This study provides Class I evidence that SM+ is superior to SM for multiple treatment maneuvers of pcBPPVcan.
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Affiliation(s)
- Michael Strupp
- Department of Neurology, German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
| | - Nicolina Goldschagg
- Department of Neurology, German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
| | - Anne-Sophie Vinck
- Department of Otolaryngology, Algemeen Ziekenhuis Brugge, Brugge, Belgium
| | - Otmar Bayer
- Department of Neurology, German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany.,ReliaTec GmbH, Garching, Germany
| | | | - Lorenzo Salerni
- Department of Otolaryngology, University of Siena, Siena, Italy
| | - Anita Hennig
- Department of Neurology, German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
| | - Dominik Obrist
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Marco Mandalà
- Department of Otolaryngology, University of Siena, Siena, Italy
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Bhandari A, Kingma H, Bhandari R. BPPV Simulation: A Powerful Tool to Understand and Optimize the Diagnostics and Treatment of all Possible Variants of BPPV. Front Neurol 2021; 12:632286. [PMID: 33841305 PMCID: PMC8032929 DOI: 10.3389/fneur.2021.632286] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 03/03/2021] [Indexed: 11/13/2022] Open
Abstract
BPPV is a mechanical disorder caused by the displacement of otolith debris into the semicircular canals. The treatment involves different repositioning maneuvers to bring the debris back into the utricle. This study aims to show how dynamic simulation models based on fluid dynamics and MRI, can help to visualize and understand the movement of the debris within the canals during head movement in 3D as a function of time. The user can define the rotation angle and plane at each step of the maneuver and then the model visualizes the canal and the otoconial movement in 3D. The simulation developed also allows alteration of various parameters like the rotational head acceleration, the duration of each step of the maneuver, the initial position of the otoconial debris in the canal, the size and the number of the particles and fluid dynamics of endolymph. The clod movement is visualized in such a way that it allows a better understanding of the impact and efficacy of various liberation maneuvers and why certain maneuvers might fail when not applied properly in the clinic. The model allows simulation of multi-canal BPPV. In this paper we demonstrate the power of the model applied on the maneuvers of Semont and Yacovino when executed in different ways. The model aims to provide a visual explanation for the need of specific maneuvers for each type of BPPV. The simulator presented here can be used to test the efficacy of existing maneuvers and help in the development of new maneuvers to treat different BPPV variants.
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Affiliation(s)
| | - Herman Kingma
- Department of Ear Nose Throat, Maastricht University, Maastricht, Netherlands.,Faculty of Physics, Tomsk State National Research University, Tomsk, Russia.,Department of Ear Nose Throat, Aalborg University, Aalborg, Denmark
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11
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Gebhart I, Götting C, Hool SL, Morrison M, Korda A, Caversaccio M, Obrist D, Mantokoudis G. Sémont Maneuver for Benign Paroxysmal Positional Vertigo Treatment: Moving in the Correct Plane Matters. Otol Neurotol 2021; 42:e341-e347. [PMID: 33165161 PMCID: PMC7880166 DOI: 10.1097/mao.0000000000002992] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
HYPOTHESIS We aimed to investigate the effect of the head excursion angle on the success of the Sémont Maneuver (SM). BACKGROUND SM is performed with the head turned by 45 degrees toward the unaffected ear. In clinical routine, it is unlikely that physicians can turn the head to a position of exactly 45 degrees. Moreover, it is unclear how possible deviations from 45 degrees would affect the outcome with SM. METHODS We used an in vitro model (upscaled by ×5) of a posterior semicircular canal with canalithiasis to study head excursion angles (0-75 degrees) and minimum waiting times in SM. Additionally, we measured actual head excursion angles performed by trained physicians during SM on a healthy subject. RESULTS Successful canalith repositioning to the utricle was possible at head excursion angles between 21 and 67 degrees. Waiting time increased from 16 to 30 seconds with increasing deviation from 45 degrees. Angles larger than 67 degrees or smaller than 21 degrees did not lead to successful repositioning even after a waiting period of 5 minutes. Physicians set head excursion angles of 50 degrees ±SD 4.8 degrees while performing the SM. CONCLUSION Angular deviations up to ±20 degrees from the ideal SCC plane (45 degrees) still allows for successful SM. Although the tested physicians tended to underestimate the actual head excursion angle by 5 degrees (and more), the success of SM will not be affected provided that the waiting time is sufficiently long. Further, the results suggest that the Brandt-Daroff maneuver is a form of habituation training rather than a liberatory maneuver.
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Affiliation(s)
- Isabel Gebhart
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital and University of Bern
| | - Carina Götting
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital and University of Bern
| | - Sara-Lynn Hool
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital and University of Bern
| | - Miranda Morrison
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital and University of Bern
| | - Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital and University of Bern
| | - Marco Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital and University of Bern
| | - Dominik Obrist
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital and University of Bern
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Giannoni B, Marcelli V, Verdolin I, Checcucci C, Pollastri F, Pecci R. Congruous Torsional Down Beating Nystagmus in the Third Position of the Semont's Maneuver in Patients Treated for Canalithiasis of Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo: Its Significance and Prognostic Value. Front Neurol 2020; 11:949. [PMID: 33071926 PMCID: PMC7533572 DOI: 10.3389/fneur.2020.00949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/22/2020] [Indexed: 11/29/2022] Open
Abstract
Due to its mechanical pathogenesis, benign paroxysmal positional vertigo treatment is mainly physical: when posterior semicircular canal is involved, Semont's maneuver is reported as one of the most effective liberating procedures. In the case of a canalolithiasis, the efficacy of the maneuver is corroborated by the appearance of some nystagmus findings during its performance. Liberating nystagmus, that can occur in the second position of Semont's maneuver and whose direction is congruous with the excitation of the affected posterior semicircular canal has proven to be a favorable prognostic sign. On the other hand, in clinical experience, we've frequently verified the appearance of another nystagmus during the execution of the maneuver: upon reaching the third position, when replacing the patient seated, a torsional down beating nystagmus, with the torsional component “congruous” with the stimulation of the vertical semicircular canals of the affected side, can often be appreciated. Such a sign can occur with or without having had the previous liberating nystagmus in the second position and is almost always associated with an intense vertigo and/or body pulsion. In this study, we describe the incidence and characteristics of the congruous torsional down beating nystagmus that can arise by assuming the third position of Semont's maneuver in a cohort of patients treated for posterior semicircular canal benign paroxysmal positional vertigo due to canalolithiasis. In the best of our knowledge, such a sign has never been described and explained before. On the basis of the pathophysiology and of the possible canal receptors stimulation during the different phases of Semont's maneuver, we formulated different hypothesis on how such a nystagmus can be generated. We observed that such a sign, when elicited, has a very good prognostic meaning for healing purposes, even better than that of liberating nystagmus. Therefore, congruous torsional down beating nystagmus should always be checked when performing Semont's maneuver because it could help in predicting success of physical treatment and in managing patients.
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Affiliation(s)
- Beatrice Giannoni
- Department of Neuroscience, Psychology, Drug's Area and Child's Health, University of Florence, Florence, Italy.,Unit of Audiology Careggi University Hospital, Florence, Italy
| | | | - Ilaria Verdolin
- Unit of Audiology Careggi University Hospital, Florence, Italy
| | - Curzio Checcucci
- Department of Physics and Astronomy, University of Florence, Italy Careggi University Hospital, Florence, Italy
| | | | - Rudi Pecci
- Unit of Audiology Careggi University Hospital, Florence, Italy
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Zuma e Maia F, Ramos BF, Cal R, Brock CM, Mangabeira Albernaz PL, Strupp M. Management of Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo. Front Neurol 2020; 11:1040. [PMID: 33041982 PMCID: PMC7522363 DOI: 10.3389/fneur.2020.01040] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/10/2020] [Indexed: 11/23/2022] Open
Abstract
Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vestibular vertigo. It is caused by free-floating otoconia moving freely in one of the semicircular canals (canalolithiasis) or by otoliths adhered to the cupula (cupulolithiasis). The posterior canal is the most common canal affected, followed by the lateral canal. Diagnosis of the side affected is critical for successful treatment; therefore, suppressing visual fixation is essential to examination of these patients' eye movement. On the basis of our experience, we have adopted the Zuma maneuver and the modified Zuma maneuver for both apogeotropic and geotropic variants of lateral canal BPPV. Knowledge of the anatomy and pathophysiologic mechanisms of the semicircular canals is essential for correct management of these patients. Hence, using a single maneuver and its modification may facilitate daily neurotological practice.
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Affiliation(s)
- Francisco Zuma e Maia
- Department of Otorhinolaryngology and INSCER, Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Bernardo Faria Ramos
- Department of Otorhinolaryngology, Federal University of Espirito Santo, Vitoria, Brazil
| | - Renato Cal
- Department of Otorhinolaryngology, University Center of Para (CESUPA), Belem, Brazil
| | - Camila Martins Brock
- Department of Otorhinolaryngology, Pontifical Catholic University of Rio Grande do Sul (PUC-RS), Porto Alegre, Brazil
| | | | - Michael Strupp
- Ludwig Maximilians University, Munich, Germany
- Department of Neurology and German Center for Vertigo and Balance Munich, Munich, Germany
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Martens C, Goplen FK, Aasen T, Gjestad R, Nordfalk KF, Nordahl SHG. Treatment of horizontal canal BPPV-a randomized sham-controlled trial comparing two therapeutic maneuvers of different speeds. Laryngoscope Investig Otolaryngol 2020; 5:750-757. [PMID: 32864448 PMCID: PMC7444789 DOI: 10.1002/lio2.420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 05/15/2020] [Accepted: 06/02/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To compare the effect of a high-speed barbecue maneuver with the modified Lempert maneuver and sham in patients with benign paroxysmal positional vertigo (BPPV) of the horizontal canal. METHODS Randomized sham-controlled, single blinded multicenter clinical trial in two university hospitals investigating consecutive patients with horizontal canal BPPV.Patients were randomly assigned to high-speed barbecue (HSB), modified Lempert maneuver (ML), or sham maneuver (SM). All treatments were performed in a biaxial rotational chair with weekly follow-up to a maximum of three treatment sessions. The final follow-up was 3 months after the last treatment. RESULTS Primary outcome: 2-week recovery rate per protocol. Secondary outcome: Cumulative recovery rate and Dizziness Handicap Inventory (DHI) scores after 3 months per protocol (HSB and ML) and intention to treat (all groups).Fifty-four patients were analyzed after 2 weeks (HSB = 17; ML = 20; SM = 17). Two-week recovery rate was 14/17 after HSB, 11/20 after ML, and 4/17 after SM, with significantly better recovery in HSB [OR 15.17, 95% CI (1.85, 124.63), P = .001] using sham as base level. Recovery rate after 3 months was 15/17 after HSB and 15/19 after ML. Cumulative recovery rate showed no significant differences between the two treatment groups [95% CI (0.30, 13.14), P = .46] in cure rate DHI [95% CI (-16.56, 15.02), P = .92]. No unexpected adverse events were observed. CONCLUSION Velocity change in horizontal canal BPPV treatment gives a faster initial recovery. Rapid recovery could reduce the disease burden. TRIAL REGISTRATION Clinicaltrials.gov. Identifier: NCT01905800. LEVEL OF EVIDENCE 1b.
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Affiliation(s)
- Camilla Martens
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology & Head Neck SurgeryHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
| | - Frederik Kragerud Goplen
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology & Head Neck SurgeryHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
| | - Torbjørn Aasen
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology & Head Neck SurgeryHaukeland University HospitalBergenNorway
| | - Rolf Gjestad
- Research DepartmentDivision of PsychiatryBergenNorway
| | - Karl Fredrik Nordfalk
- Department of Otorhinolaryngology & Head and Neck SurgeryOslo University HospitalOsloNorway
| | - Stein Helge Glad Nordahl
- Norwegian National Advisory Unit on Vestibular Disorders, Department of Otorhinolaryngology & Head Neck SurgeryHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
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Peripheral Downbeat Positional Nystagmus: Apogeotropic Posterior Canal or Anterior Canal BPPV. J Neurol Phys Ther 2020; 43 Suppl 2:S8-S13. [PMID: 30883487 DOI: 10.1097/npt.0000000000000267] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Downbeat nystagmus (DBN) during the Dix-Hallpike test (DHT) suggests excitation of the anterior canal (AC) or inhibition of the posterior canal (PC) underlying benign paroxysmal positional vertigo (BPPV). This case series describes 2 individuals presenting with DBN in positional testing suggestive of a PC BPPV variant termed apogeotropic PC-BPPV and due to inhibition of the PC. CASE DESCRIPTIONS Case 1 illustrates a DBN during positional testing (PC inhibition) that changes to an upbeating nystagmus (PC excitation) representing the otoconial material changing location and direction of movement within the PC. Case 2 describes a canal jam in the nonampullary segment of the PC. DIFFERENTIAL DIAGNOSIS Apogeotropic PC-BPPV can cause DBN due to inhibition of the vestibular afferent. Apogeotropic PC-BPPV may be due to a canal jam of debris within the nonampullary segment or cupulolithiasis with debris attached to the inferior-most aspect of the cupula within the PC. It can be difficult to differentiate AC-BPPV from the apogeotropic PC-BPPV variant. In both forms, the affected canal may be provoked in 1 or both positions of the DHT and straight head hanging position. However, in AC-BPPV there may only be a slight or absent torsional component toward the involved ear. In apogeotropic PC-BPPV, a strong torsion away from the involved ear is typically observed. The straight head hanging position may resolve AC-BPPV or convert apogeotropic PC-BPPV to typical PC-BPPV. SUMMARY These 2 cases illustrate atypical variants of BPPV that clinicians must consider in their interpretation of DBN during positional testing, particularly in the absence of other neurological signs.
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Straumann D, Brandt T. Bedside provocation and liberation maneuvers in patients with benign paroxysmal positional vertigo. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2020. [DOI: 10.1177/2514183x19881892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In the majority of cases, benign paroxysmal positional vertigo (BPPV) originates from the posterior or horizontal semicircular canals. If performed correctly, the maneuvers that diagnose or treat canalolithiasis or cupulolithiasis are highly effective. This article describes the provocation (i.e. diagnostic) and liberation (i.e. therapeutic) maneuvers to be applied in patients with BPPV. The step-by-step descriptions of the maneuvers are supplemented by practical recommendations.
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Affiliation(s)
- Dominik Straumann
- Department of Neurology, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Thomas Brandt
- Institute of Clinical Neurosciences, University Hospital Munich Großhadern, Ludwig-Maximilians-University Munich, Munich, Germany
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A Chair-based Abbreviated Repositioning Maneuver (ChARM) for fast treatment of posterior BPPV. Eur Arch Otorhinolaryngol 2019; 276:2191-2198. [PMID: 31065788 DOI: 10.1007/s00405-019-05460-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 04/30/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To assess the effectiveness of a variation of the Epley maneuver, which we have titled "Chair-based Abbreviated Repositioning maneuver (ChARM)", in solving cases of benign positional paroxysmal vertigo (BPPV) of the posterior canal. ChARM addresses multiple issues of highly overloaded medical centers that delay its due and timely resolution. For example it does not necessitate an examination bed/table and requires only a backed chair, and less than 3 min to be performed. In combination with a recently published abbreviated diagnostic maneuver it can solve BPPV cases within few minutes of single medical visit. METHODS Patients being diagnosed with posterior BPPV by means of an abbreviated diagnostic maneuver were recruited. Immediately after diagnosis, a single attempt of ChARM was conducted. The patient was followed for 48 h and at 1 month after these procedures to assess the persistence of symptomatology. RESULTS 124 patients were treated with ChARM immediately after diagnosis during their very first medical visit. 92 patients (74.2%) solved their symptomatology completely after a single attempt of ChARM. The absence of symptoms persisted during the 30 days of follow-up. DISCUSSION ChARM showed high success rates in solving posterior BPPV. The entire diagnostic-treatment procedure takes less than 5 min to perform and may allow direct treatment of patients, thereby avoiding unnecessary referrals or full vestibular testing. These abbreviated tools may be particularly useful in primary care settings or heavily overloaded otolaryngology or neurology departments.
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Wagner AR. Atypical variants of posterior canal benign paroxysmal positional vertigo after canalith repositioning: a case report. HEARING, BALANCE AND COMMUNICATION 2019. [DOI: 10.1080/21695717.2018.1534471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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