Abstract
We report on a 61-year-old woman with cupulolithiasis of the right horizontal semicircular canal, which is usually difficult to treat. The patient reported that several years ago, similar symptoms relieved completely after having performed several somersaults together with her granddaughter. This time, repetitive somersaults were again effective to treat her benign paroxysmal positional vertigo. Acceleration during a somersault may induce an intracanalicular force strong enough to detach otoconia debris from the cupula. Rolling may then promote their reentrance into the utricle. This case suggests that repetitive somersaults may be an alternative treatment of cupulolithiasis of the horizontal semicircular canal.
1
Introduction
Paroxysmal dizziness is commonly caused by benign paroxysmal positional vertigo (BPPV). In most cases of BPPV, the posterior semicircular canal is affected. To a lower extent (5%–10%), the horizontal semicircular canal is involved . The BPPV of the horizontal semicircular canal (h-BPPV) typically occurs during turning of the head while lying in a supine position. The etiology of h-BPPV can be variable. In most cases, it is idiopathic, but it can also occur posttraumatically or be induced by positioning maneuvers to treat PBPPV .
Clinically, h-BPPV is characterized by a bidirectional horizontal nystagmus, which is triggered as the head of the supine patient is turned from side to side. There are 2 subtypes of h-BPPV: (i) the canalolithiasis is caused by fragments of otoconia that move freely in the horizontal semicircular canal. In case of canalolithiasis , nystagmus is geotropic (toward the undermost ear) and more intense after rotation of the head toward the affected side. It is caused by the movement of otoconial debris within the long arm of the horizontal semicircular canal, which stimulates utriculopetal endolymph flow. The vertigo is triggered by circular acceleration of the horizontal semicircular canal (ii), if cupulolithiasis otoconia are attached to the cupula or are trapped in the proximal segment of the canal near to the cupula. As the head of the supine patient is turned slowly from side to side, the cupula is displaced, which induces asymmetric vestibular stimulation . The vertigo typically occurs when the head changes position; circular acceleration does not trigger vertigo. The nystagmus during cupulolithiasis of the horizontal semicircular canal is pathognomonically apogeotropic (away from the undermost ear) and more intense after rotation of the head toward the unaffected ear.
Interestingly, there is no effective maneuver available for the treatment of the cupulolithiasis of the horizontal semicircular canal, to date. Here, we suggest that somersaulting may be a more effective treatment maneuver, which relieves symptoms within a few days.
2
Case report
The 61-year-old woman turned to the emergency hospitalization because of rotary dizziness, which suddenly occurred after turning in bed that morning. The symptoms were accompanied by nausea and emesis. Several years ago, the patient experienced similar symptoms, which did not respond to conventional treatment, but remarkably disappeared after having performed several somersaults together with her granddaughter. Preexisting conditions are otosclerosis (surgery in 2000 and 2003) and migraine. The migraine is treated with sumatriptane (100 mg) and mergentane (50 mg) if required.
2.1
Neurologic examination
Clinical examination revealed an apogeotropic nystagmus when moving her head left and right while lying in a supine position (see video ). The nystagmus was more intense when the head was rotated to the left side.
There were no pathological findings in any other cranial nerve. Sensory and motor examination, tendon reflexes, gait, and coordination showed no signs of pathology. Physical examination of the heart, lungs, and abdomen were, accordingly, without pathological findings.
The typical history and clinical findings led to the diagnosis of the cupulolithiasis of the h-BPPV with the right horizontal semicircular canal affected. Other reasons for the dizziness were excluded. Because somersault had been previously therapeutically effective, we advised her to somersault repetitively again. Interestingly, only a few somersaults during hospitalization were necessary to decrease the symptoms remarkably and reduce nystagmus. After hospital discharge, we advised repeating the somersaults at home daily. A 6-week follow-up, examination showed no remaining symptoms and no positional nystagmus.
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