Posterior Semicircular Canal Dehiscence with Vestibulo-Ocular Reflex Reduction for the Affected Canal at the Video-Head Impulse Test: Considerations to Pathomechanisms.

Posterior semicircular canal dehiscence (PSCD) has been demonstrated to result in a third mobile window mechanism (TMWM) in the inner ear similar to superior semicircular canal dehiscence (SSCD). Typical clinical and instrumental features of TMWM, including low-frequency conductive hearing loss (CHL), autophony, pulsatile tinnitus, sound/pressure-induced vertigo and enhanced vestibular-evoked myogenic potentials, have been widely described in cases with PSCD. Nevertheless, video-head impulse test (vHIT) results have been poorly investigated. Here, we present six patients with PSCD presenting with a clinical scenario consistent with a TMWM and an impaired vestibulo-ocular reflex (VOR) for the affected canal on vHIT. In two cases, an additional dehiscence between the facial nerve and the horizontal semicircular canal (HSC) was detected, leading to a concurrent VOR impairment for the HSC. While in SSCD, a VOR gain reduction could be ascribed to a spontaneous "auto-plugging" process due to a dural prolapse into the canal, the same pathomechanism is difficult to conceive in PSCD due to a different anatomical position, making a dural herniation less likely. Alternative putative pathomechanisms are discussed, including an endolymphatic flow dissipation during head impulses as already hypothesized in SSCD. The association of symptoms/signs consistent with TMWM and a reduced VOR gain for the posterior canal might address the diagnosis toward PSCD.

Audiovestibular Findings in Patients with Concurrent Superior Canal Dehiscence and Vestibular Schwannoma.

OBJECTIVE: To describe the clinical-instrumental findings in case of concurrent superior canal dehiscence (SCD) and ipsilateral vestibular schwannoma (VS), aiming to highlight the importance of an extensive instrumental assessment to achieve a correct diagnosis. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Five patients with concurrent SCD and VS. INTERVENTION: Clinical-instrumental assessment and imaging. MAIN OUTCOME MEASURE: Clinical presentation, audiovestibular findings, and imaging. RESULTS: The chief complaints were hearing loss (HL) and unsteadiness (80%). Other main symptoms included tinnitus (60%) and pressure-induced vertigo (40%). Mixed-HL was identified in three patients and pure sensorineural-HL in 1, including a roll-over curve in speech-audiometry in two cases. Vibration-induced nystagmus was elicited in all cases, whereas vestibular-evoked myogenic potentials showed reduced thresholds and enhanced amplitudes on the affected side in three patients. Ipsilesional weakness on caloric testing was detected in three patients and a bilateral hyporeflexia in one. A global canal impairment was detected by the video-head impulse test in one case, whereas the rest of the cohort exhibited a reduced function for the affected superior canal, together with ipsilateral posterior canal impairment in two cases. All patients performed both temporal bones HRCT scan and brain-MRI showing unilateral SCD and ipsilateral VS, respectively. All patients were submitted to a wait-and-scan approach, requiring VS removal only in one case. CONCLUSION: Simultaneous SCD and VS might result in subtle clinical presentation with puzzling lesion patterns. When unclear symptoms and signs occur, a complete audiovestibular assessment plays a key role to address imaging and diagnosis.

Surgical treatment of nasal non-melanoma skin cancer using full-thickness skin graft: can antiplatelet therapy be related to a better result?

AIM: The aim of this retrospective study is to evaluate if antiplatelet therapy in elderly patients undergoing surgical excision of nasal non-melanoma skin cancer and contemporary reconstruction with full-thickness skin graft can be related to a better vitality of the graft and consequently improved aesthetic result. MATERIALS AND METHODS: Patients affected by BCC or SCC of the nose that underwent surgical excision and contemporary reconstruction with full-thickness skin graft were divided into two groups according to antiplatelet therapy. Medications were performed 7 and 15 days after surgery. To asses engraftment, we clinically evaluated the percentage of vital flap recognizing 3 different results: less than 20%, between 20% and 80%, and more than 80% of vital surface. Finally, patients were asked to express a subjective evaluation of the aesthetic result using a numeric scale ranging from 1 to 10. Statistical analyses were performed with SPSS 15.0 for Windows. RESULTS: Twenty-four of the 36 eligible patients took antiplatelet therapy (Group 1). Statistical analysis was very close to demonstrate a significant difference between the two groups after the first evaluation (X2= 3.6; p-value = 0.0578) and it showed a clear significant difference between the two groups after the second evaluation (X2 = 13.5692 e p-value = 0.0002). The average value of the subjective evaluation conducted only on 32 of 36 patients, was 9.12. Any significant difference was observed between the two groups (p-value >0.1). CONCLUSIONS: Our preliminary results seem to suggest that antiplatelet therapy in elderly patients with non-melanoma skin cancer of the nose treated with surgical excision and contemporary reconstruction with fill-thickness skin graft could favor the graft vitality with low risk of bleeding. Further studies will be useful to determinate if antiplatelet drugs can be prescribed in the perioperative period to selected patients presenting risk factors for wound healing to increase the chances of engraftment. KEY WORDS: Antiplatelet Therapy, Non Melanoma Skin Cancer, Skin Graft.

Low-Frequency Air-Bone Gap and Pulsatile Tinnitus Due to a Dural Arteriovenous Fistula: Considerations upon Possible Pathomechanisms and Literature Review.

Low-frequency air-bone gap (ABG) associated with pulsatile tinnitus (PT) and normal impedance audiometry represents a common finding in patients with third window syndromes. Other inner disorders, including Meniere's disease (MD), perilymphatic fistula and intralabyrinthine schwannoma, might sometimes result in a similar scenario. On the other hand, PT is frequently associated with dural arteriovenous fistula (DAVF), while conductive hearing loss (CHL) is extremely rare in this clinical setting. A 47-year-old patient was referred to our center with progressive left-sided PT alongside ipsilateral fullness and hearing loss. She also experienced headache and dizziness. Otoscopy and video-oculographic examination were unremarkable. Conversely, a detailed instrumental audio-vestibular assessment revealed low-frequency CHL with normal impedance audiometry, slight left-sided caloric weakness, slightly impaired vestibular-evoked myogenic potentials on the left and normal results on the video-head impulse test, consistent with an MD-like instrumental profile. Gadolinium-enhanced brain MRI revealed an early enhancement of the left transverse sinus, consistent with a left DAVF between the left occipital artery and the transverse sinus, which was then confirmed by angiography. A trans-arterial embolization with Onyx glue was performed, resulting in a complete recession of the symptoms. Post-operatively, the low-frequency ABG disappeared, supporting the possible role of venous intracranial hypertension and abnormal pressure of inner ear fluids in the onset of symptoms and offering new insights into the pathomechanism of inner ear CHL.

Impaired Vestibulo-Ocular Reflex on Video Head Impulse Test in Superior Canal Dehiscence: "Spontaneous Plugging" or Endolymphatic Flow Dissipation?

Surgical plugging of the superior semicircular canal (SSC) represents an effective procedure to treat disabling symptoms in superior canal dehiscence (SCD), despite resulting in an impaired vestibulo-ocular reflex (VOR) gain for the SSC. On the other hand, SSC hypofunction on video head impulse test (vHIT) represents a common finding in patients with SCD exhibiting sound/pressure-induced vertigo, a low-frequency air-bone gap (ABG), and enhanced vestibular-evoked myogenic potentials (VEMPs). "Spontaneous canal plugging" has been assumed as the underlying process. Nevertheless, missing/mitigated symptoms and/or near-normal instrumental findings would be expected. An endolymphatic flow dissipation has been recently proposed as an alternative pathomechanism for SSC VOR gain reduction in SCD. We aimed to shed light on this debate by comparing instrumental findings from 46 ears of 44 patients with SCD exhibiting SSC hypofunction with post-operative data from 10 ears of 10 patients with SCD who underwent surgical plugging. While no difference in SSC VOR gain values was found between the two groups (p = 0.199), operated ears developed a posterior canal hypofunction (p = 0.002). Moreover, both ABG values (p = 0.012) and cervical/ocular VEMP amplitudes (p < 0.001) were significantly higher and VEMP thresholds were significantly lower (p < 0.001) in ears with SCD compared to operated ears. According to our data, canal VOR gain reduction in SCD should be considered as an additional sign of a third window mechanism, likely due to an endolymphatic flow dissipation.

Glycyrrhizin and Mannitol Nasal Therapy: Cytological and Clinical Outcomes in Chronic Rhinitis.

Introduction Chronic rhinitis (CR) represents a widespread inflammation with a high incidence in the general population. Although it is generally considered a benign condition, CR has a relevant impact on quality of life and requires a specific treatment approach. Objective The aim of the present study was to investigate the efficacy of glycyrrhizin and mannitol intranasal treatment on chronic rhinitis using cytological analysis and subjective evaluation of symptoms. Methods A total of 55 patients suffering from chronic rhinitis were enrolled in the present study, 34 with allergic rhinitis (AR) and 21 with nonallergic rhinitis (NAR). The severity of four different nasal symptoms was determined by using a visual analogue scale (VAS). Specimens obtained by nasal scraping were collected for cytological analysis. Data were acquired before and after a 30-day treatment with glycyrrhizin and mannitol nasal spray. Statistical analyses were performed. Results The VAS scores for all four nasal symptoms considered in the present study, as well as for neutrophil cells, reduced significantly after therapy in both allergic and nonallergic patients. The number of eosinophils was not significantly lower in nonallergic patients. Conclusion A 30-day topical treatment with glycyrrhizin and mannitol may improve nasal symptoms and reduce inflammatory cells in the nasal mucosa in patients with chronic rhinitis without significant contraindications. Further studies could support our results and would better clarify all the aspects of this treatment.

Post-Infectious Acute Cerebellar Ataxia Treatment, a Case Report and Review of Literature.

BACKGROUND: infectious mononucleosis is very common during childhood and neurological manifestations are extremely rare. However, when they occur, an appropriate treatment must be undertaken to reduce morbidity and mortality as well as to ensure appropriate management. METHODS: we describe the clinical and neurological records of a female patient with post-EBV acute cerebellar ataxia, whose symptoms rapidly resolved with intravenous immunoglobulin therapy. Afterwards, we compared our results with published data. RESULTS: we reported the case of an adolescent female with a 5-day history of sudden asthenia, vomiting, dizziness, and dehydration, with a positive monospot test and hypertransaminasemia. In the following days, she developed acute ataxia, drowsiness, vertigo, and nystagmus with a positive EBV IgM titer, confirming acute infectious mononucleosis. The patient was clinically diagnosed with EBV-associated acute cerebellitis. A brain MRI showed no acute changes and a CT scan showed hepatosplenomegaly. She started therapy with acyclovir and dexamethasone. After a few days, because of her condition's deterioration, she received intravenous immunoglobulin and demonstrated a good clinical response. CONCLUSIONS: although there are no consensus guidelines for the treatment of post-infectious acute cerebellar ataxia, early intervention with intravenous immunoglobulin might prevent adverse outcomes, especially in cases that do not respond to high-dose steroid therapy.

Vestibular assessment in sudden sensorineural hearing loss: Role in the prediction of hearing outcome and in the early detection of vascular and hydropic pathomechanisms.

Introduction: Predicting hearing outcome in sudden sensorineural hearing loss (SSNHL) is challenging, as well as detecting the underlying pathomechanisms. SSNHL could be associated with vestibular damage since cochleo-vestibular structures share the same vascularization, along with being in close anatomical proximity. Whereas viral inflammations and autoimmune/vascular disorders most likely represent the involved aetiologies, early-stage Menière's disease (MD) can also present with SSNHL. Since an early treatment could beneficially influence hearing outcome, understanding the possible etiology plays a pivotal role in orienting the most appropriate treatment. We aimed to evaluate the extent of vestibular damage in patients presenting with SSNHL with or without vertigo, investigate the prognostic role of vestibular dysfunctions on hearing recovery and detect specific lesion patterns related to the underlying pathomechanisms. Methods: We prospectively evaluated 86 patients with SSNHL. Audio-vestibular investigation included pure-tone/speech/impedance audiometry, cervical/ocular-VEMPs, vHIT and video-Frenzel examination. White matter lesions (WML) were evaluated on brain-MRI. Patients were followed-up and divided into "SSNHL-no-vertigo," "SSNHL+vertigo" and "MD" subgroups. Results: Hearing was more impaired in "SSNHL+vertigo" patients who exhibited either down-sloping or flat-type audiograms, and was less impaired in "MD" where low frequencies were mostly impaired (p < 0.001). Otolith receptors were more frequently involved than semicircular canals (SCs). Although the "SSNHL-no-vertigo" subgroup exhibited the lowest vestibular impairment (p < 0.001), 52% of patients developed otolith dysfunctions and 72% developed nystagmus. Only "MD" subjects showed anterior SC impairment and upbeating spontaneous/positional nystagmus. They more frequently exhibited cervical-VEMPs frequency tuning (p = 0.036) and ipsilesional spontaneous nystagmus (p < 0.001). "SSNHL+vertigo" subjects presented with more frequently impaired cervical-VEMPs and posterior SC and with higher number of impaired receptors (p < 0.001). They mainly exhibited contralesional spontaneous and vibration-induced nystagmus (p < 0.05) and only they showed the highest WML score and "vascular" lesion patterns (p < 0.001). Concerning the outcomes, hearing was better in "MD" and worse in "SSNHL+vertigo" (p < 0.001). Hearing recovery was mostly affected by cervical-VEMPs impairment and the number of involved receptors (p < 0.05). Patients with "vascular" lesion patterns presented with the highest HL degree and WML score (p ≤ 0.001), while none of them exhibited a complete hearing recovery (p = 0.026). Conclusions: Our data suggest that vestibular evaluation in SSNHL can provide useful information on hearing recovery and underlying aetiologies.

Malignant trichilemmal carcinoma misdiagnosed with parotid gland malignant tumor.

Malignat proliferating trichilemmal tumor (MPTT) are rare tumors usually presenting in photo-exposed areas, especially on the face, scalp, neck,and dorsal part of the hand. Differential diagnosis include squamous cell carcinoma, basal-cell carcinoma, keratoacanthoma and malignant nodular melanoma, so that only incisional biopsy can lead to pre-operative diagnosis. We present case MPTT misdiagnosed with parotid gland malignant tumor that underwent radical surgical excision and adijuvant radiotherapy.

Glycyrrhizin and Mannitol Nasal Therapy: Cytological and Clinical Outcomes in Chronic Rhinitis

Abstract Introduction Chronic rhinitis (CR) represents a widespread inflammation with a high incidence in the general population. Although it is generally considered a benign condition, CR has a relevant impact on quality of life and requires a specific treatment approach. Objective The aim of the present study was to investigate the efficacy of glycyrrhizin and mannitol intranasal treatment on chronic rhinitis using cytological analysis and subjective evaluation of symptoms. Methods A total of 55 patients suffering from chronic rhinitis were enrolled in the present study, 34 with allergic rhinitis (AR) and 21 with nonallergic rhinitis (NAR). The severity of four different nasal symptoms was determined by using a visual analogue scale (VAS). Specimens obtained by nasal scraping were collected for cytological analysis. Data were acquired before and after a 30-day treatment with glycyrrhizin and mannitol nasal spray. Statistical analyses were performed. Results The VAS scores for all four nasal symptoms considered in the present study, as well as for neutrophil cells, reduced significantly after therapy in both allergic and nonallergic patients. The number of eosinophils was not significantly lower in nonallergic patients. Conclusion A 30-day topical treatment with glycyrrhizin and mannitol may improve nasal symptoms and reduce inflammatory cells in the nasal mucosa in patients with chronic rhinitis without significant contraindications. Further studies could support our results and would better clarify all the aspects of this treatment.

Use of Irrigation Device for Duct Dilatation during Sialendoscopy.

BACKGROUND: Continuous irrigation of the duct with isotonic saline is one of the fundamental stages of a successful sialendoscopic procedure. It allows for an adequate luminal distension for the removal of debris and mucous plugs and for the conservative treatment of strictures. This procedure, which commonly involves the use of a medical syringe, can be laborious, and it is often necessary to interrupt irrigation during surgery due to the high resistance to saline. SETTING: Academic university hospital. METHOD: We propose the use of an irrigation device which consists of a high-pressure syringe barrel, an ergonomic piston handle, and a gauge used to monitor the inflation and deflation of balloon catheters. The system allows for a simple and safe dilation, ensuring good visualization of the salivary duct lumen during sialendoscopy. CONCLUSIONS: The irrigation system described can be widely used to perform a diagnostic or interventional sialendoscopy more effectively than with a typical manual irrigation procedure.

Prevention of Recurrent Benign Paroxysmal Positional Vertigo: The Role of Combined Supplementation with Vitamin D and Antioxidants.

Benign paroxysmal positional vertigo (BPPV) usually has a favorable course, although it is possible to observe BPPV with a high recurrence rate. Previous studies suggested that vitamin D deficiency might affect BPPV recurrences, and oxidative stress might play a complementary role in BPPV pathogenesis. This multicentric trial aimed to evaluate the effectiveness of oral nutritional supplementation with a compound of alpha-lipoic acid, Carnosine, and Zinc (LICA® (Difass International, Coriano (RN), Italy)), vitamins of group B and vitamin D in preventing BPPV recurrences. A total of 128 patients with high recurrence-BPPV were randomized in three arms: Arm 1 consisted of subjects with "insufficient" or "deficient" vitamin D blood levels, treated with daily oral supplementation of LICA®, vitamins of group B and vitamin D3 (800 UI), Arm 2 included BPPV subjects with "sufficient" vitamin D who did not receive any nutritional support, and Arm 3 included subjects with a "sufficient" serum concentration of vitamin D who received supplementation with a compound of LICA® and Curcumin. After six months of follow-up, a significant reduction of BPPV relapses compared to the baseline was found only in Arm 1 (−2.32, 95% CI: 3.41−1.62, p-value < 0.0001). Study results suggested that oral nutritional supplementation with vitamin D3 plus antioxidants can prevent relapses in patients suffering from high recurrence-BPPV.

Is it possible to diagnose Posterior Semicircular Canal BPPV from the sitting position? The role of the Head Pitch Test and the upright tests along the RALP and LARP planes.

PURPOSE: The diagnosis of benign paroxysmal positional vertigo (BPPV) involving the posterior semicircular canal (PSC) is traditionally entrusted to positioning tests where patients are rapidly brought in the supine position. This prospective study aims to define the role of a diagnostic protocol for PSC-BPPV including only upright tests. MATERIALS AND METHODS: 109 patients with PSC-BPPV were enrolled. The Head Pitch Test (HPT) was carried out first. If uneventful, the patient's head was turned 45° to each side and bent back-and-forth along the plane aligning either with the right anterior-left posterior (RALP) or left anterior-right posterior (LARP) canals, thus performing the upright RALP / upright LARP (uRALP/uLARP) test. Nystagmus observed was used to predict the diagnosis, which was therefore confirmed by Dix-Hallpike tests. RESULTS: PSC-BPPV could be correctly diagnosed in 75.2% of cases with the sole HPT and in 87.2% of cases by adding the uRALP/uLARP test (Upright Protocol). The time elapsed from symptoms onset was closely related to the protocol sensitivity, as it reached 100% (64/64) in acute patients while decreased to 68.9% (31/45) in cases evaluated after 7 days (p < 0.001). CONCLUSIONS: Upright maneuvers could correctly diagnose PSC-BPPV in most cases. uRALP/uLARP test demonstrated to improve the sensitivity of the HPT, mainly in recent-onset BPPV.

Recovery of Regular Daily Physical Activities Prevents Residual Dizziness after Canalith Repositioning Procedures.

OBJECTIVE: Residual dizziness is a disorder of unknown pathophysiology, which may occur after repositioning procedures for benign paroxysmal positional vertigo. This study evaluates the relationship between regular daily physical activity and the development of residual dizziness after treatment for benign paroxysmal positional vertigo. STUDY DESIGN: Prospective observational cohort study. SETTING: Academic university hospital. METHODS: Seventy-one patients admitted with benign paroxysmal positional vertigo involving the posterior semicircular canal were managed with Epley's procedure. Three days after successful treatment, the patients underwent a telephone interview to investigate vertigo relapse. If the patients no longer complained of vertigo, they were asked about symptoms consistent with residual dizziness. Subsequently, they were asked about the recovery of physical activities they regularly performed prior to the onset of vertigo. RESULTS: Sixty-nine patients (age: 57.79 ± 15.05) were enrolled: five (7.24%) reported vertigo relapse whereas twenty-one of sixty-four non-relapsed patients (32.81%) reported residual dizziness. A significant difference in the incidence of residual dizziness was observed considering the patients' age (p = 0.0003). Of the non-relapsed patients, 46 (71.88%) recovered their regular dynamic daily activities after treatment and 9 (19.57%) reported residual dizziness, while 12 of the 18 patients (66.67%) who did not resume daily activity reported residual symptoms (p = 0.0003). A logistic regression analysis showed a significant association between daily activity resumption and lack of residual dizziness (OR: 14.01, 95% CI limits 3.14-62.47; p = 0.001). CONCLUSIONS: Regardless of age, the resumption of regular daily physical activities is associated with a lack of residual dizziness.

Minimum Stimulus Strategy: A step-by-step diagnostic approach to BPPV.

Benign Paroxysmal Positional Vertigo (BPPV) is among the most common vestibular disorders, characterized by brief vertigo spells triggered by head position changes with abrupt onset and rapid decrease. BPPV is ascribed to otoconial matter dislodged from utricular macula and attached to the cupula of the affected semicircular canal (cupulolithiasis) or free-floating within its lumen (canalolithiasis). According to the vestibulo-ocular reflex pathophysiology, each cupular deflection, either exciting or inhibiting the corresponding ampullary afferents, generates the contraction of specific extraocular muscles couples leading to pathognomonic nystagmus. The Upright BPPV Protocol (UBP) is a diagnostic approach to BPPV conducted in the sitting position slowly bending the patient's head along the spatial axes, aiming to move canaliths by gravity within the involved semicircular canal, under continuous nystagmus monitoring by video-Frenzel goggles. UBP starts with the evaluation of pseudo-spontaneous nystagmus in the primary gaze position and continues with the upright Head Pitch Test (uHPT) by forward and backward head bendings along the pitch plane. The uHPT can indicate whether horizontal or vertical semicircular canal is involved. If horizontal canal is suspected, the upright Head Roll Test (uHRT) usually provides the diagnosis of the involved side and arm by tilting the patient's head rightward and leftward along the roll plane. Conversely, canalolithiasis involving the posterior semicircular canal can be diagnosed with the uHPT alone. Nevertheless, if necessary, the diagnostic sensitivity can be increased by head movements along the right anterior - left posterior (RALP) and left anterior - right posterior (LARP) canal planes (uRALP/uLARP test). Following the UBP, most BPPV form can be diagnosed in upright position, allowing clinicians to proceed immediately with proper physical treatment and avoiding unpleasant maneuvers to patients.

Spontaneous Jamming of Horizontal Semicircular Canal Combined with Canalolithiasis of Contralateral Posterior Semicircular Canal.

Spontaneous canalith jam is an uncommon form of benign paroxysmal positional vertigo mimicking acute vestibular neuritis. We described for the first time a spontaneous horizontal semicircular canalith jam associated with a typical canalolithiasis involving contralateral posterior semicircular canal (PSC), illustrating how the latter condition modified direction-fixed nystagmus during head movements. An 81-year-old woman with persistent vertigo referred to our center. Video-Frenzel examination showed horizontal direction-fixed right-beating nystagmus in primary gaze position, inhibited by visual fixation. She exhibited corrective saccades after leftward head impulses. Chin-to-chest positioning at the head-pitch test did not modify spontaneous nystagmus, whereas slight torsional components with the top pole of the eye beating toward the right ear appeared in backward head-bending, resulting in mixed horizontal-torsional nystagmus. At supine positioning tests, direction-fixed nystagmus turned into direction-changing geotropic horizontal nystagmus, which was stronger on the left side, while overlapping upbeat nystagmus with torsional right-beating components appeared on the right. Primary clinical findings were consistent with a left horizontal semicircular canalith jam, inducing a persistent utriculofugal cupular displacement, combined with a typical right-sided PSC-canalolithiasis. Once canalith jam crumbled, resulting in a non-ampullary arm canalolithiasis of the horizontal semicircular canal, both involved canals were freed by debris with appropriate repositioning procedures.

Spontaneous Upbeat Nystagmus and Selective Anterior Semicircular Canal Hypofunction on Video Head Impulse Test: A New Variant of Canalith Jam?

We describe a rare case of spontaneous upbeat nystagmus (UBN) attributable to a canalith jam involving the anterior semicircular canal (ASC) in a patient in whom comprehensive vestibular assessment was useful to identify the underlying pathomechanism. A 56-year-old woman with unsteadiness following repositioning procedures for left-sided benign paroxysmal positional vertigo (BPPV) presented with spontaneous UBN that showed slight right torsional components. A vestibular test battery detected isolated left ASC hypofunction on a video-head impulse test (Video-HIT). We postulated a persistent utriculopetal deflection of the left ASC cupula, which was attributable to entrapment of debris in a narrow canal tract, with consequent sustained inhibition of the ampullary afferents. Although spontaneous UBN receded after impulsive physical therapy, unsteadiness deteriorated into positional vertigo secondary to canalolithiasis involving the ipsilateral posterior canal. In our view, physical therapy possibly fragmented the canalith jam and released free-floating otoconia that eventually settled into the ipsilateral posterior canal. Video HIT revealed normalization of ASC hypofunction, and leftsided posterior canal canalolithiasis was successfully treated using appropriate repositioning procedures. We propose that a canalith jam involving the ASC should be considered in the differential diagnosis of spontaneous UBN, particularly in patients with a history of BPPV and isolated ASC hypofunction detected on video HIT.