Early subclinical cochlear dysfunction in myotonic dystrophy type 1.

BACKGROUND: Myotonic dystrophy type 1 (DM1) is an autosomal-dominant inherited disorder clinically characterized by variable systemic manifestations. Among clinical features of the disease, 'precocious presbyacusis' has been previously reported. The underlying mechanism of this auditory impairment remains still poorly understood. Hearing is an active process located in the cochlea, where the outer hair cells (OHCs) play an important role in sound perception through a 'contractile' like movement resembling skeletal muscle fibers dynamics. OHCs status has not yet been investigated in DM1 patients. OHCs integrity can be assessed by measuring transient-evoked otoacoustic emissions (TEOAE), a non-invasive, repeatable, and objective quantitative tool. METHODS: We recruited 25 patients with a genetically confirmed diagnosis of DM1, and 28 age-matched control subjects. All of them underwent a routine audiological evaluation and TEOAE recordings. RESULTS: We detected a high prevalence of sensorineural high-frequency hearing loss (HFHL) in DM1 patients, significantly different if compared to control subjects. Interestingly, the accurate analysis of DM1 recorded data showed a marked impairment of TEOAE both in HFHL+ and unexpectedly in HFHL- group. Cochlear dysfunction was restricted to frequencies above 2000 Hz in the HFHL- group, but it extended to 1000 Hz in HFHL+ DM1 patients. CONCLUSIONS: Our study indicates that cochlear impairment in DM1 is present, even in patients without evidence of hearing loss at a standard audiometric analysis. Hence, in the current clinical practice, an assessment of cochlear function by TEOAE recording may be useful in DM1 patients to identify precocious signs of cochlear dysfunction.

Functional taping applied to upper limb of children with hemiplegic cerebral palsy: a pilot study.

Functional taping with elastic bandages and adhesive tapes could limit the action of upper limb spastic muscles and sustain that of weaker muscles in children with hemiplegic cerebral palsy (CP). 16 young children with CP (3±2 years old) were enrolled in this pilot study including 5 months of taping in conjunction with conventional physical therapy, followed by 7 months of physical therapy alone (taping wash-out), and other 5 months of taping plus therapy. Large improvements in the Melbourne assessment score were found in the first period in which taping was used (+15.4%, p<0.001) and also in the second one despite 8 drop-outs (+8.4%, p=0.012), but not during the taping wash-out (- 4.6%; p=0.093). These results suggest that children with CP could benefit from the continuous correction provided by taping in order to limit the development of improper upper limb motor schemas and to favour that of proper ones.

Cough sensors. V. Pharmacological modulation of cough sensors.

Several airway afferent nerve subtypes have been implicated in coughing. These include bronchopulmonary C-fibers, rapidly adapting airway mechanoreceptors and touch-sensitive tracheal Adelta-fibers (also called cough receptors). Although the last two afferent nerve subtypes are primarily sensitive to mechanical stimuli, all can be acted upon by one or more different chemical stimuli. In this review we catalogue the chemical agents that stimulate and/or modulate the activity of the airway afferent nerves involved in cough, and describe the specific mechanisms involved in these effects. In addition, we describe the mechanisms of action of a number of chemical inhibitors of these afferent nerve subtypes, and attempt to relate this information to the regulation of coughing in health and disease.

Converting apogeotropic into geotropic lateral canalolithiasis by head-pitching manoeuvre in the sitting position.

Liberatory treatment of lateral canalolithiasis is more effective for the geotropic, than for the apogeotropic forms and, therefore, it is worthwhile attempting to convert the apogeotropic forms into the geotropic forms. In 36 cases of apogeotropic lateral canalolithiasis, one to five Head-Pitch Manoeuvres were performed in the sitting position (Head-Pitch Test) in the attempt to transform apogeotropic into geotropic lateral canalolithiasis. The Head Pitch Test was performed by a quick 60 degrees forward-flexion and a slow maximal backward-extension of the head. The Head-Pitch Test was effective in 36.1% of cases, less than the repeated Head-Rolling in the supine position, but it was always well tolerated by patients. The quick 60 degrees forward-flexion of the head can evoke a horizontal nystagmus beating towards the healthy side in apogeotropic lateral canalolithiasis and towards the affected side in geotropic lateral canalolithiasis (Bow Nystagmus). Slow backward-extension of the head can evoke a horizontal nystagmus beating towards the affected side in apogeotropic lateral canalolithiasis and toward the healthy side in geotropic lateral canalolithiasis (Lean Nystagmus). Conversion from apogeotropic to geotropic lateral canalolithiasis by the Head-Pitch Test was effective when Bow and Lean Nystagmus changed directions or when the Head-Pitch Test evoked Bow Nystagmus toward the affected side and Lean Nystagmus toward the healthy side. Conversion occurred in 10 patients during the 60 degrees forward-flexion of the head. In contrast, in 3 patients, it occurred during extension of the head, when a "Lean Nystagmus" toward the healthy side appeared. In addition, Pseudospontaneous Nystagmus and Positioning Nystagmus that arose when the patient moved from the sitting to the supine position changed direction or were evoked ex-novo, both directed toward the healthy side. In all cases, Pagnini-McClure diagnostic manoeuvre confirmed the transformation with a Positional Paroxysmal Horizontal Geotropic Nystagmus, which was more intense when the affected ear was brought down. The Head-Pitch Test can be used as the method of choice to transform apogeotropic into geotropic lateral canalolithiasis. However, anterior flexion of the head in the geotropic forms must be avoided since involuntary and harmful transformations from the geotropic into the apogeotropic form can occur, moving otoliths towards the anterior arm and cupula.

Sensitivity and specificity of vestibular bed-side examination in detecting VIII cranial nerve schwannoma with sensorineural sudden unilateral hearing loss as presenting symptom.

The objectives of this study were to identify signs of vestibular nerve suffering through a bedside vestibular examination protocol in case of sudden sensorineural unilateral hearing loss without spontaneous signs of vestibular impairment and to propose a bed-side vestibular examination based protocol for the focused execution of gadolinium-enhanced magnetic resonance imaging (MRI) only if a vestibular schwannoma is suspected. 96 patients, 52 men, 44 women, mean age 57.73 +/- 12.85 years, suffering from sudden sensorineural unilateral hearing loss, which presented neither vertigo nor spontaneous nystagmus, were enrolled. Pure tone audiometry, tympanometry, measurement of acoustic reflexes and Anderson test to detect adaptation, bedside vestibular examination through head shaking test, vibration test, head impulse test, hyperventilation test and detection of nystagmus in supine and lateral decubitus to search for signs of vestibular impairment were performed. Patients with signs of vestibular impairment and pure tone audiometry threshold at high frequencies better than 70 dB nHL were subjected to auditory brainstem responses. Gadolinium enhanced MRI centred on internal acoustic canals was carried out in all patients with sudden sensorineural unilateral hearing loss. Main outcome measures were signs of vestibular impairment at vestibular bedside examination and presence of vestibular schwannoma on MRI. Signs of vestibular impairment were detected in 22/96 cases (22.9%); a vestibular schwannoma was detected by MRI in 5/96 cases (5.2%), always when vestibular impairment was present. In case of sudden sensorineural unilateral hearing loss, vestibular bedside examination seems to be useful to restrict the suspicion of a vestibular schwannoma to cases with signs of vestibular impairment, reducing the number of MRI exams, with considerable economic savings.

The Role of Balloon Sinuplasty in the Treatment of Vacuum Rhinogenic Headache.

In this study we tried to demonstrate how balloon sinuplasty could be an option in the treatment of the Rhinogenic Headache due to a probably disventilation of frontal sinus recess. 107 patients were included in the study with diagnosis of Rhinogenic Headache. The surgical group underwent bilateral balloon sinuplasty of the frontal sinus. The medical group underwent pharmacological treatment. Headaches characteristics were evaluated by a clinical personal diary. The severity was recorded by Visual Analog Scale 4 and 8 months after treatment. 98 out of 107 patients completed the protocol. In surgical group and in medical one the mean headache score improved at four and eight months follow up. The headache frequency attacks per month decrease from a preoperative frequency of 18 (±4 SD) in surgical group and 17 (±3 SD) in medical group to 3 (±1 SD) and 6 (±3 SD) respectively at 4 months control but increased slightly to 5 (±2 SD) and 12 (±4 SD) after 8 months. We concluded that the balloon sinuplasty should be considered as an effective alternative option after an accurate selection of surgical candidates. However, it is important a 6-8 month follow-up to evaluate the efficacy and stability of the treatment used.

Respiratory action of capsaicin microinjected into the nucleus of the solitary tract: involvement of vanilloid and tachykinin receptors.

1. The respiratory response to microinjection of capsaicin into the commissural nucleus of the solitary tract (cNTS) of urethane-anaesthetized rats was investigated in the absence and presence of the competitive vanilloid (capsaicin) antagonist, capsazepine, and selective tachykinin NK1, NK2 and NK3 antagonists (RP 67580, SR 48968 and SR 142801, respectively). 2. Microinjection of capsaicin reduced respiratory frequency but not tidal volume (VT), leading to an overall reduction in minute ventilation (VE). The effect was dose-dependent between 0.5 and 2 nmol capsaicin. Doses greater than 2 nmol produced apnoea. Tachyphylaxis was observed following repeated injection of capsaicin (1 nmol, 30 min apart). 3. Capsazepine (1 nmol) had no effect on frequency or VT when injected alone but completely blocked the respiratory response to capsaicin (1 nmol). 4. RP 67580 (1 but not 5 nmol) alone depressed frequency and VT slightly. Moreover, RP 67580 appeared to potentiate the bradypnoeic effect of capsaicin. In contrast, SR 48968 and SR 142801 (1 and 5 nmol) alone had no significant effect on respiration. However, both agents significantly attenuated the reduction in frequency produced by capsaicin. 5. In conclusion, microinjection of capsaicin into the cNTS decreases overall ventilation, primarily by reducing frequency. The action of capsaicin appears from the data to be mediated by vanilloid receptors since it is blocked by the competitive vanilloid antagonist capsazepine and is subject to tachyphylaxis. However, since NK2 (SR 48968) and NK3 (SR 142801) receptor antagonists block the actions of capsaicin, we propose that capsaicin acts also by releasing tachykinins from central afferent terminals in the cNTS.

Respiratory actions of tachykinins in the nucleus of the solitary tract: characterization of receptors using selective agonists and antagonists.

1. The respiratory response to microinjection of tachykinins and analogues into the commissural nucleus of the solitary tract (cNTS) of urethane-anaesthetized rats was investigated in the presence and absence of selective tachykinin NK(1), NK(2) and NK(3) antagonists (RP 67580, SR 48968 and SR 142801, respectively). 2. All tachykinins, except for the selective NK(2) agonist, [Nle(10)]-NKA(4-10), increased tidal volume (VT). The rank potency order of naturally-occurring tachykinins was neurokinin A (NKA)> or =substance P (SP)>>NKB, whereas the rank order for selective analogues was senktide> or = septide>> [Sar(9),Met(O(2))(11)]-SP>>[Nle(10)]-NKA(4-10). Septide (NK(1)-selective) and senktide (NK(3)-selective) were 22 fold more potent (pD(2) approximately 12) at stimulating VT than SP (pD(2) approximately 10.5). 3. Tachykinin agonists produced varying degrees of respiratory slowing, independent of changes in VT. At doses producing maximum stimulation of VT, agonists induced either a mild (<10 breaths min(-1) decrease; SP and septide), moderate (10 - 25 breaths min(-1) decrease; NKA, NKB and [Sar(9),Met(O(2)]-SP) or severe ( approximately 40 breaths min(-1) decrease; senktide) bradypnoea. [Nle(10)]-NKA(4-10) produced a dose-dependent bradypnoea without affecting VT. 4. RP 67580 significantly attenuated the VT response to SP (33 pmol) and NKA (10 pmol) but not NKB (100 pmol). In the presence of RP 67580, the mild bradypnoeic response to NKB was significantly enhanced whereas SP and NKA induced a bradyapnea which was not observed in the absence of RP 67580. SR 48968 had no effect on the VT response to SP or NKB, markedly enhanced the VT response to NKA and completely blocked the bradypnoeic response to [Nle(10)]-NKA(4-10). Only SR142801 attenuated the VT response to NKB. 5. The present data suggest that all three tachykinin receptors (NK(1), NK(2) and NK(3)) are present in the cNTS and are involved in the central control of respiration.

Respiratory actions of tachykinins in the nucleus of the solitary tract: effect of neonatal capsaicin pretreatment.

1. The respiratory response to microinjection of capsaicin and tachykinin receptor agonists into the commissural nucleus of the solitary tract (cNTS) was investigated in adult, urethane-anaesthetized rats which had been pretreated with capsaicin (50 mg kg(-1) s.c.) or vehicle (10% Tween 80, 10% ethanol in saline) as day 2 neonates. 2. Microinjection of capsaicin (1 nmol) into the cNTS of vehicle-pretreated rats, significantly reduced respiratory frequency (59 breaths min(-1), preinjection control, 106 breaths min(-1)) without affecting tidal volume (VT). In capsaicin-pretreated rats, the capsaicin-induced bradypnoea was markedly attenuated (minimum frequency, 88 breaths min(-1); control, 106 breaths min(-1)). 3. In vehicle-pretreated rats, microinjection of substance P (SP, 33 pmol), neurokinin A (NKA, 33 pmol) and NKB (330 pmol), and the selective NK(1) tachykinin receptor agonists, [Sar(9), Met(O(2))(11)]-SP (33 pmol) and septide (10 pmol), increased VT (maxima, 3.60 - 3.93 ml kg(-1)) compared with preinjection control (2.82 ml kg(-1)), without affecting frequency. The selective NK(3) agonist senktide (10 pmol) also increased VT (3.93 ml kg(-1)) which was accompanied by a bradypnoea (-25 breaths min(-1)). The selective NK(2) agonist, [Nle(10)]-NKA(4-10) (330 pmol) increased VT slightly but significantly decreased frequency (-12 breaths min(-1)). In capsaicin-pretreated rats, VT responses to SP and [Sar(9), Met(O(2))(11)]-SP were increased whereas the response to septide was abolished. Both the VT and bradypnoeic responses to senktide and [Nle(10)]-NKA(4-10) were significantly enhanced. 4. These results show that neonatal capsaicin administration markedly reduces the respiratory response to microinjection of capsaicin into the cNTS. The destruction of capsaicin-sensitive afferents appears to sensitize the NTS to SP, NKB, [Sar(9),Met(O(2))(11)]-SP, senktide and [Nle(10)]-NKA(4-10). Moreover, the loss of septide responsiveness in capsaicin-pretreated rats, suggests that 'septide-sensitive' NK(1) receptors may be located on the central terminals of afferent neurons.

Multiple mechanisms of reflex bronchospasm in guinea pigs.

The mechanisms of histamine- and bradykinin-induced reflex bronchospasm were determined in anesthetized guinea pigs. With intravenous administration, both autacoids evoked dose-dependent increases in tracheal cholinergic tone. Vagotomy or atropine prevented these tracheal reflexes. When delivered as an aerosol, bradykinin readily increased tracheal cholinergic tone, whereas histamine aerosols were much less effective at inducing tracheal reflexes. Also, unlike histamine, bradykinin could evoke profound increases in cholinergic tone without directly or indirectly (e.g., prostanoid dependent) inducing measurable airway smooth muscle contraction resulting in bronchospasm. Neither autacoid required de novo synthesis of prostanoids or nitric oxide to induce reflex tracheal contractions. Combined cyclooxygenase inhibition and tachykinin-receptor antagonism did, however, abolish all effects of bradykinin in the airways, whereas responses to histamine were unaffected by these pretreatments. The data indicate that histamine and bradykinin initiate reflex bronchospasm by differential activation of vagal afferent nerve subtypes. We speculate that selective activation of either airway C fibers or airway rapid adapting receptors can initiate reflex bronchospasm.

Altered respiratory response to substance P and reduced NK1 receptor binding in the nucleus of the solitary tract of aged rats.

The respiratory response to microinjection of substance P (SP) into the commissural nucleus of the solitary tract (cNTS) and binding of [125I]-Bolton-Hunter SP ([125I]-BHSP) to brain stem NK1 receptors were compared in young and aged rats. Injection of SP (750 pmol) into the cNTS of young rats (2 months) increased tidal volume (VT) but had no effect on respiratory rate (f). In aged rats (19-21 months), injection of SP had no significant effect on f or VT. The NTS of aged rats displayed significantly lower specific [125I]-BHSP binding than young rats, indicating a reduction in the number in NK1 receptors. These findings show that the respiratory response to microinjection of SP into the cNTS of aged rats is severely blunted and that this phenomenon may be due to a decrease in the number of NK1 receptors in the NTS.

Autoradiographic localisation of substance P (NK1) receptors in human primary visual cortex.

This study utilised autoradiography to examine [125I]-Bolton Hunter substance P (BHSP) binding in postmortem human visual cortex. In the primary visual area, layers I-III, IVC and VI exhibited low levels of BHSP binding, while high levels were observed in layers IVB and V. Because cells in layers IVB and V are known to be involved in processing direction-specific stimuli, it is possible that SP plays a role in modulating this visual process.

Hypoxia attenuates the respiratory response to injection of substance P into the nucleus of the solitary tract of the rat.

Prolonged or repetitive bouts of hypoxia may desensitize the brain stem respiratory centres leading to reduced stimulation of ventilation. We investigated the possible involvement of changes in the sensitivity of the commissural nucleus of the solitary tract (cNTS) to the tachykinin peptide, substance P (SP). Urethane-anaesthetised rats were allowed to breath room air (normoxic) or subjected to four, 30 s bouts of hypoxia (10% O2/90% N2) prior to the injection of SP (750 pmol) into the cNTS. In normoxic rats (n = 5), SP produced a fall in frequency (f, 88+/-4% control) after 4 min and a maximum rise in tidal volume (VT) after 6 min (138+/-10% control) leading to an overall increase in minute ventilation (VE, maximum, 127+/-12% control after 2 min). In rats (n = 5) exposed to four bouts of hypoxia and allowed to recover for 10 min, injection of SP produced a similar fall in f but a delayed and significantly (P < 0.001) reduced VT (maximum after 10 min, 110+/-1% control) and hence, VE response (104+/-3% control). Sixty min after hypoxia, the f, VT and VE responses to SP were identical to those of normoxic rats. These data suggest that hypoxia desensitizes SP receptors in the cNTS and this may partly explain why the respiratory response to hypoxia declines over time.

Effect of a broad-spectrum cephalosporin on the oral and intestinal microflora in patients undergoing colorectal surgery.

The influence of ceftriaxone on oral and intestinal flora was investigated in 10 patients undergoing colorectal surgery. Ceftriaxone was given intravenously in one 2g dose before anesthesia. Saliva and feces samples were collected and analyzed on day 0, 3, 5, 14 and 28 after drug administration. All specimens were cultured quantitatively for aerobic and anaerobic microorganisms; representative colonies of each morphologic type of organism cultured were identified. The oral aerobic flora was somewhat affected by the administration of ceftriaxone. In all patients the number of Streptococci, Staphylococci and Neisseria decreased during the 5 days after ceftriaxone administration. No significant changes in the number of anaerobic commensal occurred. The oral microflora of all patients after 14 days had returned to normal. The aerobic fecal flora was considerably affected: in all patients enterobacteria were eliminated or strongly suppressed. Only minor changes in the number of aerobic gram-positive bacteria were observed, and the anaerobic intestinal flora showed only minor alterations. On day 28 the intestinal flora were normalized in all respects. No new colonizing microorganisms were isolated during the investigation period and no colonization with ceftriaxone-resistant bacteria was observed. No postoperative infection occurred and no adverse effects were registered.

Synthesis and local anesthetic activity of alkylaminoacyl derivatives of 2-amino-1,3,4-thiadiazole.

We prepared some series of 2-(alkylaminoacyl) derivatives of 2-amino-1,3,4-thiadiazoles. Most terms were subjected to a biological screening showing a local anesthetic activity both in infiltration and trunkular tests. For some of the assayed derivatives, the activity was comparable to that of lidocaine, taken as the reference molecule. From the obtained results an acceptable relationship between some structural features and activity was drawn.

Synthesis of carboxyalkylthio-triazoles and bicyclic derivatives with antiinflammatory and analgesic activity.

3-Carboxyalkylthio derivatives of 5-alkoxyphenyl-1,2,4-triazole were prepared, performing some substitutions both on carboxyalkyl chain, by lengthening it or introducing substituents with increasing molecular weight in alpha- at the carboxy group, and on N-4 atom in the triazole ring, by introducing an amino or methyl group, so that to vary steric conformation along with the lipophilicity of molecules. The corresponding bicyclic thiazolo-triazolone and triazolo-thiazinone derivatives, which represent the rigid models of carboxymethylthio- and carboxyethylthio- open structures, were also obtained. All the compounds show "in vivo" antiinflammatory activity, while only carboxyalkylthio derivatives of 4-amino- and 4-methyltriazole display an appreciable analgesic one. From the relief of some data on substituent present in the synthesized compounds, a structure-activity relationship is also suggested.

MAOI activity of thiosemicarbazides and related 2-thiazolylhydrazines.

The preparation is described of hydrazides I, thiosemicarbazides II, III, IV and hydrazinothiazoles VIII, which can be considered as "precursors" or "open models" for the synthesized benzoyl-, benzilidene- and benzyl-hydrazinothiazoles V, VI and VII, analogous to 4-methyl and 4-phenyl substituted derivatives A, B and C, described and tested for their MAOI activity in a previous paper. Biochemical assay on the new prepared compounds allowed us to better clarify the structure-activity relationship also of compounds A, B and C of the precedent note. Moreover, on a group of derivatives, which showed a higher activity, a further test was performed to observe the possible correlation between MAOI activity and both their lipophilicity and ability in interacting with liposome bilayers, taken as a model of cell membrane.

MAOI activity of some novel series of substituted thiazol-2-yl-hydrazines.

Three series of 2-thiazolylhydrazines were synthetized and evaluated for their MAO inhibitory (MAOI) activity, both by in vivo tests, to assay their influence on several MAOI activity-related parameters (the variation on blood pressure induced by tyramine and clonidine and L-amfetamine-induced hypermotility) and in vitro tests, to assay their effect on rat brain mitochondria by a kinuramine fluorimetric assay. In vivo, all the tested compounds significatively influenced the evaluative parameters used. As regards in vitro test, all compounds displayed MAOI activity at a concentration of 1.10(-4) mol.l-1, which was significant in several cases. In the discussion of the results, the influence of the structure on the biological activity of the prepared compounds was delineated.

Sensations and regional brain responses evoked by tussive stimulation of the airways.

Stimuli that evoke cough in humans also elicit a sensation described as the urge-to-cough. This sensation is perceived at levels of stimulation below the threshold for coughing and increases in intensity in response to higher levels of stimulation. Cough in humans can be consciously modified in intensity or suppressed altogether, and the urge-to-cough is likely to contribute to discretionary responses to tussive stimulation. Converging evidence from animal and human experiments have identified a widely distributed network of brain regions that are implicated in the representation of urge-to-cough and the control of coughing. This network incorporates regions that show responses associated with urge-to-cough ratings, such as limbic and somatosensory cortices, as well as paralimbic and premotor regions implicated in response inhibition that activate in association with efforts to suppress cough. The urge-to-cough can be influenced by psychological factors and preliminary findings suggest that these effects could be mediated by top-down influences. There is considerable impetus to understand circuits involved in the modulation of urge-to-cough because it may be possible to antagonise the troubling sensation while preserving the critical cough reflex.

Anterior canal BPPV and apogeotropic posterior canal BPPV: two rare forms of vertical canalolithiasis.

Posterior canal benign paroxysmal positional vertigo (BPPV) is the most frequent form of BPPV. It is characterized by a paroxysmal positioning nystagmus evoked through Dix-Hallpike and Semont positioning tests. Anterior canal BPPV (AC) is more rare than posterior canal BPPV; it presents a prevalent down beating positioning nystagmus, with a torsional component clockwise for the left canal, counterclockwise for the right canal. Due to the possible lack of the torsional component, it is sometimes difficult to identify the affected ear. An apogeotropic variant of posterior BPPV (APC) has recently been described, characterised by a paroxysmal positional nystagmus in the opposite direction to the one evoked in posterior canal BPPV: the linear component is down-beating, the torsional component is clockwise for the right canal, counter-clockwise for the left canal, so that a contra-lateral anterior canal BPPV could be simulated. During a 16 month period, of 934 BPPV patients observed, the authors identified 23 (2.5%) cases of apogeotropic posterior canal BPPV and 11 (1.2%) cases of anterior canal BPPV, diagnosed using the specific oculomotor patterns described in the literature. Anterior canal BPPV was treated with the repositioning manoeuvre proposed by Yacovino, which does not require identification of the affected side, whereas apogeotropic posterior canal BPPV was treated with the Quick Liberatory Rotation manoeuvre for the typical posterior canal BPPV, since in the Dix-Hallpike position otoliths are in the same position if they come either from the ampullary arm or from the non-ampullary arm. The direct resolution of BPPV (one step therapy) was obtained in 12/34 patients, 8/23 patients with APC and 4/11 patients with AC; canalar conversion into typical posterior canal BPPV, later treated through Quick Liberatory Rotation (two-step therapy), was obtained in 19 patients,14/23 with APC and 5/11 with AC. Three patients were lost to follow-up. Considering the effects of therapeutic manoeuvres, the authors propose a grading system for diagnosis of AC and APC: "certain" when a canalar conversion in ipsilateral typical posterior canal BPPV is obtained; "probable" when APC or AC are directly resolved; "possible" when disease is not resolved and cerebral neuroimaging is negative for neurological diseases. Our results show that the oculomotor patterns proposed in the literature are effective in diagnosing APC and AC, and that APC is more frequent than AC. Both of these rare forms of vertical canal BPPV can be treated effectively with liberatory manoeuvres.