Abstract
Objective
The purpose of this study was to evaluate the presence and eventually to study the features of spontaneous nystagmus (Ny) in our patients with diagnosis of benign paroxysmal positional vertigo (BPPV).
Patients and methods
We retrospectively reviewed the clinical records of patients who presented with vertigo spells and were managed at our tertiary care referral center. Patients with only idiopathic BPPV presenting with typical vertigo spells and positioning Ny characteristic of the disease were included in this study. To investigate the positioning Ny, we studied the patients in the sitting position, during the head shaking test, and during the Dix-Hallpike test and the McClure-Pagnini test (Ny provoked by rotation of the head in a supine patient). Ny responses in all patients were observed using infrared videoscopy.
Results
We managed 412 patients affected by BPPV. Of the 412 patients, 292 (70.87%) were diagnosed to be having posterior canal-BPPV and 110 (26.99%) patients had horizontal canal-BPPV (HC-BPPV). The remaining 10 patients (2.44%) were identified to have anterior canal-BPPV. Spontaneous Ny in sitting position was observed, by infrared videoscopy, only in the patients affected by HC-BPPV.
Conclusion
Spontaneous Ny in BPPV can be observed with infrared videoscopy in patients affected by HC-BPPV. The origin of this Ny is most likely due to a natural inclination of horizontal semicircular canal with respect to the horizontal plane. This Ny stops after flexion of the head in neutral position, and for this reason, it should be considered as a seemingly spontaneous Ny. This Ny, in our experience, is observed in most HC-BPPV patients but does not indicate the need for a different management protocol or any different prognostic value of HC-BPPV.
1
Introduction
Benign paroxysmal positional vertigo (BPPV) is a biomechanical disorder of the posterior labyrinth in which one or more of the semicircular canals are inappropriately stimulated by loose otoconia upon certain head movements and positions, resulting in brief episodes of vertigo .
Although the exact etiology for this dysfunction is still unclear, it is thought to be secondary to inner ear trauma or pathologies such as vestibular neuronitis, circulatory failure of anterior vestibular artery, and labyrinthitis . Even then, more than 50% of all reported cases are identified to be idiopathic in nature .
Prevalence of BPPV is estimated to be about 107 cases for every 100 000 population per year and is reported more often in women than in men. It is seen most frequently in middle-aged and older adults. Rarely, it can occur in children too .
Diagnosis of BPPV is based mainly on a history of characteristic positional vertigo along with the classical clinical signs. The nystagmus (Ny) typically has a latency of a few seconds and is of limited duration, transient, fatigable, and reversible upon return to upright position .
Benign paroxysmal positional vertigo most commonly involves the posterior semicircular canal. During the Dix-Hallpike maneuver, Ny seen in posterior canal type of BPPV (PC-BPPV) is typically torsional, upbeating with the torsional component beating toward the lowermost ear . The Ny in horizontal canal type of BPPV (HC-BPPV) may beat toward the ground (geotropic) or away from the ground (apogeotropic) , whereas the head is turned to either side in the supine position.
In 2002, Bertholon et al observed a torsional downbeating Ny during Hallpike maneuver, and it has been invoked to explain BPPV from the anterior semicircular canal (AC-BPPV).
Although the features of Ny in BPPV have been well studied, very few studies highlight the presence of spontaneous Ny in positional vertigo. Only 4 articles are present in literature about this poorly understood aspect.
Von Brevern et al were the first to describe a spontaneous Ny in BPPV in a 2001 study. They described a patient with BPPV of right horizontal semicircular canal (HSC) who showed spontaneous Ny beating to the left that disappeared after the rehabilitation maneuver. Successively, Bisdorff and Debatisse in 2002 discovered this sign in 2 patients affected by apogeotropic form of HC-BPPV. Asprella-Libonati in 2005 and in 2008 revealed that overall 66% of HC-BPPV examined by him was associated with a spontaneous Ny that resolved after repositioning maneuver.
The purpose of this study was to evaluate the presence and eventually to study the features of spontaneous Ny in our patients with diagnosis of BPPV.
2
Patients and methods
We retrospectively reviewed the clinical records of patients who presented with vertigo spells and were managed at our tertiary care referral center (ENT Institute of “G. d’Annunzio” University of Chieti-Pescara, Italy) for a 3-year period (2003–2006). Patients with only idiopathic BPPV presenting with typical vertigo spells and positioning Ny characteristic of the disease and with a follow-up of at least 2 weeks were included in this study. Patients without the required follow-up, patients with multiple semicircular canals involvement, with neurologic or psychiatric disease, with other forms of peripheral or central vertigo, and with head trauma were excluded from this study. Cerebellopontine angle tumors mimicking BPPV were also excluded from this study.
In fact, repeated failure of repositioning maneuvers and persistence of the signs and symptoms of vertigo, along with unilateral hearing loss justified radiologic investigations to rule out an intracranial pathology .
Four hundred twelve patients with diagnosis of idiopathic BPPV qualified for the final study. All patients underwent a detailed neuro-otologic examination that included clinical history, otoscopy, pure tone audiometry, and tympanometry.
Quality of life (QoL) was evaluated pre and post management by the Dizziness Handicap Inventory (DHI) .
To investigate the positioning Ny, we studied the patients in the sitting position, during the head shaking test, and during the Dix-Hallpike test and the McClure-Pagnini test (Ny provoked by rotation of the head in a supine patient) ( Fig. 1 ).
Ny responses in all patients were observed using infrared videoscopy (VNS from ULMER, Synapsys Inc, France-USA).
We focused our attention to latency, limited duration, fatigue, and repetition of Ny during the diagnostic maneuvers.
After the diagnosis of BPPV, all patients were treated with canalith repositioning maneuver (CRM) according to the affected semicircular canal. We used the Semont’s maneuver or the modified Epley’s maneuver for treating PC-BPPV . For the HC-BPPV, in accordance with the personal experience of Riggio et al , we used the Barbecue maneuver or the Gufoni maneuver. Anterior canal-BPPV was treated using the Epley maneuver modified for the anterior semicircular canal as described by Herdmann [ ].
Patients in the primary and secondary care centers were treated with vestibular suppressant drugs such as betahistine, cinnarizine, and benzodiazepines before being referred to us. We did the neuro-otologic assessments in these patients only after a period of 48 hours from taking the last dose of the medicine.
The repositioning maneuvers were performed immediately after diagnosis, and persistence of Ny and vertigo spells after CRM indicated failure of treatment and required its repetition. No medical treatments were given to patients before or after the diagnostic tests or repositioning maneuvers.
All patients were followed up for at least 2 weeks, and we repeated the videoscopy examination and the DHI evaluation according to our protocol ( Fig. 2 ).
Patients affected by idiopathic BPPV and with presence of spontaneous Ny were subjected to bithermal energy test 2 weeks after CRM so as to rule out any unilateral labyrinthine damage.
2
Patients and methods
We retrospectively reviewed the clinical records of patients who presented with vertigo spells and were managed at our tertiary care referral center (ENT Institute of “G. d’Annunzio” University of Chieti-Pescara, Italy) for a 3-year period (2003–2006). Patients with only idiopathic BPPV presenting with typical vertigo spells and positioning Ny characteristic of the disease and with a follow-up of at least 2 weeks were included in this study. Patients without the required follow-up, patients with multiple semicircular canals involvement, with neurologic or psychiatric disease, with other forms of peripheral or central vertigo, and with head trauma were excluded from this study. Cerebellopontine angle tumors mimicking BPPV were also excluded from this study.
In fact, repeated failure of repositioning maneuvers and persistence of the signs and symptoms of vertigo, along with unilateral hearing loss justified radiologic investigations to rule out an intracranial pathology .
Four hundred twelve patients with diagnosis of idiopathic BPPV qualified for the final study. All patients underwent a detailed neuro-otologic examination that included clinical history, otoscopy, pure tone audiometry, and tympanometry.
Quality of life (QoL) was evaluated pre and post management by the Dizziness Handicap Inventory (DHI) .
To investigate the positioning Ny, we studied the patients in the sitting position, during the head shaking test, and during the Dix-Hallpike test and the McClure-Pagnini test (Ny provoked by rotation of the head in a supine patient) ( Fig. 1 ).
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