A new office-based procedure for treatment of snoring: The S.I.Le.N.C.E. study.

OBJECTIVE: Demonstrate the safety and effectiveness of palatal foreshortening and stiffening in reducing snoring severity in nonobstructive sleep apnea (non-OSA) patients complaining of chronic disruptive snoring. METHODS: In a US-based 8-center, open-label, prospective, single-arm cohort study, 52 consenting adults with chronic disruptive snoring (snoring impacting a patient's life and causing patient or bed partner to seek medical intervention) were treated via office-based placement of resorbable, bidirectional, barbed suture implants into the soft palate under local anesthesia. Prior to intervention, home sleep tests (HSTs) were performed to rule out OSA and to document snoring noise level. Both subject and their bed/sleep partners (also consented) completed questionnaires including: bed/sleep partner's scored visual analog scale (VAS) for subjects' snoring severity, and subject scoring for Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI). Following intervention, HSTs, VAS, ESS and PSQI were repeated at 30, 90 and 180 days. RESULTS: Mean baseline bed/sleep partner VAS was 7.81 ± 1.59. Mean postimplant VAS scores decreased significantly at each measured interval; to 5.77±2.35 (P < .001) at 30 days, 4.48 ± 1.81 (P < .001) at 90 days, and 5.40 ± 2.28 (P < .001) at 180 days. Post treatment improvements in daytime sleepiness and QOL were also observed. Two partial extrusions were reported. No further adverse events were identified. CONCLUSION: The current study demonstrates the safety and efficacy of the Elevoplasty procedure in reducing snoring severity over a follow-up period of 6 months. LEVEL OF EVIDENCE: 2b.

Totally implantable hearing system: Five-year hearing results.

OBJECTIVES/HYPOTHESIS: 1) To provide long-term hearing outcome measures of a totally implantable hearing system (implant) and compare to the baseline unaided (BLU) and baseline aided (BLA) conditions, and 2) discuss relevant safety measures. STUDY DESIGN: Prospective, nonrandomized, multicenter, single-subject-as-own-control design. METHODS: Fifty-one subjects with mild to severe sensorineural hearing loss were implanted between 2008 and 2009 and enrolled in this postmarket approval study in the setting of private and hospital-based practices. Forty-nine of these subjects completed the 5-year study, which included annual follow-ups. Primary effectiveness endpoints were speech reception threshold (SRT) and word recognition scores at 50 dB (WRS50s). Secondary effectiveness endpoints were WRSs and the Abbreviated Profile of Hearing Aid Benefit (APHAB) scores. Adverse Device Effects (ADEs) and Serious Adverse Device Effects (SADEs) reported during the study period and a comparison of bone conduction scores are submitted as safety measures. RESULTS: Compared to the BLA condition, 1) SRT scores were improved at every annual follow-up; 2) WRS50s were better in 49%, and the same in 41% at the 5-year follow-up; 3) WRSs were improved by 17% at the 5-year follow-up; and 4) APHAB scores were improved in most subscales at every annual follow-up. There were three SADEs in three subjects and 15 ADEs in 11 subjects. Bone conduction scores increased by 3.7 dB at the 5-year follow-up. Average battery life was 4.9 years. CONCLUSIONS: The implant compared favorably to the subjects' hearing aid throughout the 5-year period in all of the areas measured and was found to be safe. LEVEL OF EVIDENCE: 2b. Laryngoscope, 128:210-216, 2018.

Nasal obstruction and recurrent sinusitis caused by bilateral pneumatized ethmoid bullae.

The presentation of an enlarged pneumatized bulla ethmoidalis (BE) that obstructs the ethmoid infundibulum has not been previously reported. We report such a case in a 23-year-old woman who presented with recurrent acute rhinosinusitis and chronic rhinosinusitis. The obstruction had been caused by inferior and anterior pneumatization of the BE. Surgery was successful in alleviating all symptoms, and the patient remained symptom-free at 10 months of follow-up. We describe the radiologic and endoscopic findings in this case, and we discuss the possible mechanisms by which BE is involved in the pathogenesis of recurrent acute and chronic rhinosinusitis.

Efficacy of targeted middle meatal antibiotics and endoscopic sinus surgery.

BACKGROUND: Postoperative infection remains a significant comorbidity of endoscopic sinus surgery (ESS) delayed healing, synechia formation, etc. The objective of this study was to compare the incidence of postoperative infection after ESS in patients receiving conventional postoperative oral antibiotic prophylaxis versus a synthetic bioabsorbable antibiotic-soaked nasal sponge used in the middle meatus (MM) in lieu of oral antibiotics. METHODS: A prospective randomized multicenter trial included 321 chronic rhinosinusitis patients undergoing minimally invasive ESS who received either 1 week of oral antibiotics and a saline-soaked bioabsorbable MM sponge (control group) or no oral antibiotics and the placement of a bacitracin-soaked bioabsorbable sponge in the MM (study group). Evaluations performed at baseline, 3-weeks, and 3-months postoperatively included the 20-item Sino-Nasal Outcome Test and nasal endoscopic examination. RESULTS: The 3-week postoperative infection rate was not significantly different between the study (n = 165) and control groups (n = 156): 5.4% versus 3.8%; p > 0.05. In addition, there was no significant difference between the two patient groups on evaluation of MM granulations, synechia, middle turbinate lateralization, or sponge retention. CONCLUSION: Antibiotic-soaked synthetic bioabsorbable MM sponges show equivalent efficacy in controlling post ESS infections compared with conventional postoperative oral antibiotics. Topical antibiotic delivery to the MM via bioabsorbable sponges may reduce the need for postoperative systemic antibiotics and provide a cost-effective alternative that eliminates the issues of antibiotic side effects, drug-drug interactions, and medication compliance in the postoperative setting.

Balloon dilation technology: let the truth be told.

Balloon dilation technology (BDT), also known as balloon sinuplasty, has been in clinical use since September, 2005. Prior to BDT, surgeons performed a procedure called FESS, or functional endoscopic sinus surgery, for patients with chronic sinusitis. As is true with any new technology or procedure in medicine, a debate often ensues between early adopters and mainstream practitioners. Over the past 7 years, much has been discussed, debated, and learned about BDT. What follows is a review of the origins of the BDT: the theory, technology, indications and applications; and a review of the pertinent outcomes literature. Independent of how one feels about BDT, the evidence strongly supports its safety, efficacy, and growing popularity among patients and physicians alike.

Balloon catheter dilatation of Eustachian tube: a preliminary study.

OBJECTIVE: Eustachian tube dysfunction is a common problem and transnasal endoscopic balloon dilation of the Eustachian tube (ET) is a new surgical technique. The goal of this study is to review the evolution of this novel technique and study the preliminary outcomes. SUBJECTS AND METHODS: Balloon catheter dilation of the 100 Eustachian tubes in 70 adults was performed at a tertiary medical center from January 2009 to January 2011. A 5-mm sinus balloon catheter was endoscopically placed transnasally into the proximal ET to dilate the cartilaginous ET. Cases were reviewed with respect to indications, outcomes, and complications. RESULTS: Of the 100 ETs, ear fullness and pressure were improved in 71% of patients studied for 26.3 weeks (± 3.6). Of 8 patients followed for a minimum of 34 months, 87% reported persistent improvement. One complication is reported. CONCLUSION: Endoscopic transnasal ET balloon dilation is a novel approach to treating ET dysfunction. Benefits can be durable up to 3 years. This technique holds much promise and merits further investigation.

Profound high-frequency sensorineural hearing loss treatment with a totally implantable hearing system.

OBJECTIVE: This study seeks to assess the efficacy of the Envoy Esteem totally implantable hearing device in treating profound high-frequency sensorineural hearing loss. PATIENTS: Five patients with profound high-frequency hearing loss participating in a prospective, multi-center, nonrandomized Food and Drug Administration clinical trial. INTERVENTION: Implantation with Esteem totally implantable hearing device and comparison to baseline unaided and aided conditions. MAIN OUTCOME MEASURE: Speech reception threshold and word recognition scores (WRS) at 50 dB HL presentation level. RESULTS: Preoperative speech reception threshold improved from an unaided 65 dB and aided 48 dB average to 26 dB with the Esteem at 12 months. WRS at 50 dB scores improved from an unaided 10% and aided 23% average to 78% postoperatively. CONCLUSION: The Esteem totally implantable middle ear hearing device provides appreciable functional gain and improvement in WRS to rehabilitate hearing in patients with a profound high-frequency sensorineural hearing loss.

Envoy Esteem Totally Implantable Hearing System: phase 2 trial, 1-year hearing results.

OBJECTIVES: (1) To assess outcomes of the Envoy Esteem Totally Implantable Hearing System as measured by hearing results compared with preimplant baseline unaided (BLU) and best-fit aided conditions (BLA) and (2) to determine safety of the device. STUDY DESIGN: Prospective, nonrandomized, multicenter, subject-as-own-control, US Food and Drug Administration (FDA) trial. SETTING: Private practice and hospital-based. SUBJECTS AND METHODS: Between January 2008 and August 2009, an FDA trial was performed at 3 sites. Fifty-seven subjects with bilateral, mild to severe sensorineural hearing loss, with discrimination greater than 40%, were implanted. Implanted components were (1) a sound processor and (2) 2 piezoelectric transducers (a sensor and a driver). A sound processor was implanted in the temporal bone. Transducers were coupled to the ossicles. Devices were activated 2 months postimplant. Hearing results were compared with ipsilateral BLU and BLA. RESULTS: Speech reception thresholds (SRTs) improved from BLA of 41.2 dB to 29.4 dB with the Esteem (P ≤ .001). Word recognition score (WRS) at 50 dB hearing level (HL) improved from BLA of 46.3% to 68.9% with the Esteem. Pure tone averages improved by 27 ± 1 dB (confidence interval, 30-25). There were no changes in bone conduction. QuickSIN results showed no change. There were 6 serious adverse device effects: 2 wound infections (1 resolved medically, 1 required explantation), 1 delayed facial paralysis that resolved with medication, and 3 revisions due to limited benefit. CONCLUSION: Phase 2 results at 12 months post implant demonstrated that (1) hearing results with the device are statistically superior to baseline best-fit hearing aids for SRT and WRS and (2) the device is safe.

A feasibility study to evaluate a novel drug delivery technique through nasal/sinus mucosa using a biodegradable polymer in a guinea pig model.

OBJECTIVE: Targeted topical pharmaceuticals have fewer side effects than systemic therapy and present an interesting option to treat chronic sinus disease. A simple, dependable, resorbable drug delivery mechanism has been elusive. The goal of this study is to examine the feasibility of a novel bioresorbable synthetic polymer for drug delivery in nose and sinuses. STUDY DESIGN: Feasibility study. SETTING: Animal study. SUBJECTS AND METHODS: Polyurethane sponges soaked in either triamcinolone or gentamicin were placed in the ethmoid cavities of 14 guinea pigs via an external approach; 2 additional animals served as controls. Serum levels of each drug were assayed at intervals up to 21 days. Histopathological examination of the relevant sinonasal anatomy of each animal was performed after 21 days. RESULTS: Serum levels of each drug were detectable between days 1 and 21. There were no significant differences in the histopathological examination of nasal mucosa in guinea pigs in which either drug was applied compared with control animals in which the bioabsorbable material was soaked in saline. The polyurethane sponge did not cause any foreign body reaction, granuloma, or polypoidal change to the sinus mucosa. Two animals developed a subclinical infection at the surgical site. CONCLUSION: The targeted use of topical pharmaceuticals via a synthetic bioresorbable nasal sponge dressing in this guinea pig model demonstrated minimal systemic absorption and minimal histopathological changes. This technology is currently under investigation in human clinical trials.

Clinical evaluation of a fully synthetic middle meatal stent for safety and tolerability.

OBJECTIVE: To evaluate the safety and tolerability of a novel, fully synthetic, poly-urethane middle meatal dressing after endoscopic sinus surgery (ESS). STUDY DESIGN: Case series with planned data collection. SETTING: Tertiary care medical facility. SUBJECTS AND METHODS: In total, 104 patients with medically refractory chronic rhinosinusitis were treated with patient-appropriate ESS and a poly-urethane sponge placed into their middle meatus at the end of operation, giving a total of 173 middle meatus stent placements. Patients were then assessed immediately postoperatively and 2, 6, 12, and 16 weeks after surgery for adverse systemic or local reaction to the stent and the incidence of postoperative infections. RESULTS: There was no pain or allergic reaction encountered with this new material. There were 11 middle meati (6.4%; 95% confidence interval, 3.2%-11.1%) with postoperative infection at 2 weeks follow-up. There were no other stent-related local reactions (ie, excessive bleeding, middle meatal synechia, or granulation) up to 16 weeks postoperatively. Residual middle meatal stent material was either absent or negligible at 2 weeks postoperatively. CONCLUSIONS: This first fully synthetic poly-urethane middle meatal dressing used during ESS demonstrated excellent biocompatibility and safety. The incidence of localized postoperative infection was also low.

The MicroFlow Spacer: A Drug-Eluting Stent for the Ethmoid Sinus.

To evaluate the short-term outcomes and safety of a newly introduced drug-eluting ethmoid stent. Prospective study of 23 patients with a total of 40 implanted ethmoid sinuses. Two tertiary care medical facility. Twenty-three patients with medically refractory chronic rhinosinusitis were treated with patient-appropriate endoscopic sinus surgery, with the modification of treating the ethmoid sinuses with an ethmoid stent infused with triamcinolone, instead of conventional endoscopic ethmoidectomy. Patients were then followed up over 6 months. Outcomes were assessed by interval changes in 20-item Sino-Nasal Outcome Test (SNOT-20) and Lund-MacKay CT scores. Safety was determined by adverse events. Overall, the pre-op SNOT-20 mean score was 2.18, versus post-op score of 1.02, an improvement of 1.16 that was both statistically (P < 0.001) and clinically significant. Ethmoid-specific and side-specific Lund-MacKay mean scores both also showed statistically significant improvements. Pre-op ethmoid-specific Lund-MacKay mean score was 1.93, versus post-op score of 1.10, an improvement of 0.83 (P < 0.001). Pre-op side-specific Lund-MacKay mean score was 5.75, compared with post-op score of 2.95, an improvement of 2.80 (P < 0.001). There were no significant intra-op or post-op complications encountered. This triamcinolone-infused ethmoid stent appears safe and effective in treating chronic ethmoid sinus disease within the defined follow-up period. The ability to deliver medication directly to diseased mucosa holds wide-ranging potential.

Inflammatory pseudotumor of the skull base.

INTRODUCTION: Inflammatory pseudotumor is an idiopathic, non-neoplastic mass lesion with few cases reported in the literature involving only the skull base and related structures. Imaging of skull-base pseudotumors shows characteristics similar to that of nasopharyngeal carcinoma and lymphoma, thereby requiring a biopsy to exclude malignancy. Surgical versus medical management relates to the location of the mass, the extent of bony invasion, and the involvement of corresponding anatomic structures. METHODS: A retrospective chart review of patients diagnosed with inflammatory pseudotumor of the skull base from a single tertiary care institution over a five-year period. RESULTS: Five cases of skull-base pseudotumor have been identified and followed from one to four years. In our clinical experience, maintenance oral corticosteroids have proven effective in improving symptoms and significantly reducing radiologic tumor dimensions. CONCLUSION: Inflammatory pseudotumor of the skull base is a challenging diagnosis due to its occult anatomic location, vague associated symptoms, and nonspecific histology. Low-dose oral corticosteroids are often very effective in management.

In-office surgical repair of nasal valve stenosis.

BACKGROUND: Nasal valve (NV) stenosis is a well-known cause of nasal obstruction (NO) and congestion but it is often overlooked because the typical surgical therapies are complex and often associated with cosmetic changes. A simplified surgical procedure is needed to address straightforward stenosis of the NV in patients with no need of cosmetic improvement or cartilage grafting. The purpose of this article is to describe a simplified surgical procedure to relieve symptoms of NO without extensive surgical dissection, sedation, cartilage grafting, or cosmetic change. METHODS: This article describes a retrospective consecutive case series of patients that underwent a surgical procedure to correct NV stenosis in the office setting. The procedure is described in detail along with patient outcome assessment using a visual analog scale of patient satisfaction and a questionnaire regarding perceived postoperative cosmetic changes. RESULTS: Of 190 patients that underwent the procedure, 36 were done in the office setting and 28 completed the questionnaires. Six patients (21%) reported an improvement score of 10, a score of maximal improvement in breathing. The mean breathing score was 4.4, indicating an overall improvement in breathing ability after correction. No patient reported a major cosmetic change and three patients reported a subtle change. The remainder (89%) reported no perceived change in cosmesis. CONCLUSION: In-office surgical correction of the NV specifically targeting the mucosa, fibrous tissue, and caudal upper lateral cartilage was feasible, safe, and reliable in relieving complaints of NO due to uncomplicated NV stenosis.

Balloon dilation of the frontal recess in patients with chronic frontal sinusitis and advanced sinus disease: an initial report.

OBJECTIVES: Balloon dilation of the sinus ostia and transition spaces is a relatively new tool in the management of chronic rhinosinusitis. Although studies of its safety and application have been reported, its efficacy in specific indications has yet to be clearly defined. The purpose of this study was to evaluate the use of balloon dilation of the frontal recess for the treatment of chronic frontal sinusitis in patients with advanced sinus disease. METHODS: This was a prospective study of 20 patients who presented with chronic frontal sinusitis that had failed medical therapy and required operative intervention. Balloon dilation of the frontal recess was performed to improve drainage and ventilation of the frontal sinus. Preoperative and postoperative computed tomography scans were compared for change in the radiologic stage of disease based both on the Lund-Mackay staging system and on the Lund grade (extent of mucosal thickening). RESULTS: Twenty patients met the inclusion criteria during the study period and were followed for several months after operation. All patients underwent a frontal sinus procedure with balloon dilation either alone or in concert with other minimally invasive techniques. A total of 29 sinuses were available for analysis. No significant complications resulted from the procedure. Pretreatment and posttreatment Lund-Mackay scores showed significant improvement in patients with certain subsets of chronic rhinosinusitis. CONCLUSIONS: Balloon dilation of the frontal recess is a relatively safe intervention that can be used in the treatment of chronic frontal sinusitis, even in patients with advanced disease.

Correlation of bone SPECT scintigraphy with histopathology of the ethmoid bulla: preliminary investigation.

OBJECTIVES: Reports in the rhinology literature suggest that osteitis of the ethmoid bone may be responsible for refractory and/or recurrent sinusitis. If so, bone scanning technologies capable of detecting osteitis may be useful in diagnosing this condition and its response to treatment. The objective of this prospective cohort study was to determine the correlation of single photon emission computed tomography (SPECT) bone scintigraphy with the histopathology of the ethmoid bulla. METHODS: Thirty-six patients with a diagnosis of chronic sinusitis who were scheduled to undergo sinus surgery underwent a presurgical SPECT bone scan using technetium 99m-methylene diphosphonate. All bone scans were done within 5 days of surgery. During the procedure, bone samples from the face of the ethmoid bulla were obtained and examined by a pathologist blinded to the bone scan result. In this study, histopathology consistent with osteitis was defined as a change from lamellar to woven bone. A positive bone scan was defined by the presence of increased radiotracer uptake in the ethmoid sinuses. RESULTS: Thirty-two of the 36 patients had a positive bone scan on SPECT imaging, and 31 specimens demonstrated histopathologic bone changes consistent with osteitis, for a sensitivity of 93.9%. An additional 4 patients had a negative bone scan on SPECT imaging, and osteitis was identified in 2 of the 4. The specificity was 66.7%, and the positive predictive value was 96.9%. CONCLUSIONS: We found that SPECT bone scanning with technetium 99m-methylene diphosphonate is a highly sensitive test for identifying osteitis in patients with chronic rhinosinusitis. It may be a useful tool in the armamentarium of the otolaryngologist to better define this disease process.

Correlation between computed tomography and bone single photon emission-computed tomography scintigraphy in patients with chronic rhinosinusitis.

BACKGROUND: Computed tomography (CT) has been the imaging study of choicefor evaluating chronic rhinosinusitis (CRS). 99mTc-MDP bone single photon emission-computed tomography (SPECT) has proven useful at identifying inflammation of bone and its use in CRS has been discussed recently. No studies, however, have documented the correlation between these two imaging modalities in CRS. METHODS: A retrospective analysis was performed of 30 patients with CRS who underwent CT and SPECT scan of the paranasal sinuses. Increased radiotracer uptake during SPECT scan was compared with CT findings graded on the Lund-Mackay score (LMS). The findings of the two imaging modalities were compared and evaluated for standard correlative statistics for diagnostic tests. RESULTS: SPECT imaging was abnormal in 25/30 patients, and CT was abnormal in 27/30 patients. Correlation between the two was highest for the ethmoid sinuses at 73.3%. SPECT had a high positive predictive value for mucosal inflammation on CT of 84.1%. Approximately 25% of individual sinuses with a positive SPECT in patients without prior surgery were not positive in corresponding sinuses onl CT. There was a positive correlation between the LMS and the number of SPECT positive sinuses within the same patient (r = 0.486; p = 0.006). CONCLUSION: 99mTc-MDP SPECT scan in patients with CRS is shown to be a useful indicator of bone involvement. The relatively high rate of bone involvement in the absence of mucosal inflammation as seen in this study warrants additional research and the potential need for different therapies than are currently available.

Initial U.S. pilot study: palatal implants for the treatment of snoring.

OBJECTIVE: To assess efficacy of polyethylene terephthalate (PET) implants in the soft palate for the treatment of socially significant snoring. DESIGN: A prospective, interventional case series. SETTING: Hospital-based multi-specialty clinic. PATIENTS: Twenty-five consecutive patients with socially significant snoring without history of obstructive sleep apnea. INTERVENTION: Three PET implants were inserted into the soft palate of each patient (Pillar procedure, Restore Medical, Inc., St. Paul, Minnesota). MAIN OUTCOME MEASURE: Change in snoring severity measured by the bed partner using a 10-centimeter visual analog scale (VAS) where 0 = "no snoring noise" and 10 = "extreme snoring noise causing (the bed partner) to leave the bedroom." RESULTS: Ninety-day follow-up data was collected for 21 patients. Four patients had incomplete follow-up. Snoring VAS rated by the bed partner had a baseline mean value of 8.5 +/- 1.4, which decreased to 5.0 +/- 2.1 at 30 days and to 4.4 +/- 2.5 at 90 days (P < 0.001). All patients tolerated the procedure well and no procedure-related complications were observed. Two implants partially extruded in 1 patient within the 90-day follow-up period, for an implant partial extrusion rate of 2.7% (2/75 implants) and patient partial extrusion rate of 4% (1/25 patients). At 90 days, 75% of patients and 90% of their bed partners recommended the procedure. CONCLUSIONS: In this case series, PET implants into the soft palate significantly reduced snoring with few extrusions and no complications. Controlled studies are needed to confirm effectiveness and to refine patient selection criteria. EBM RATING: C-4.

Office versus operating room insertion of the bone-anchored hearing aid: a comparative analysis.

BACKGROUND: The Bone-anchored Hearing Aid is indicated for patients with unilateral deafness and/or an irreversible conductive hearing loss. The insertion of this device is usually performed in the operating room under intravenous sedation or general anesthesia. We suggest that the placement of the abutment can occur easily and safely in the clinic setting, reducing time and costs for both the patient and the physician. STUDY DESIGN: Retrospective study. METHODS: Ten patients requiring 11 devices (1 bilateral) were implanted with the Bone-anchored Hearing Aid device in the outpatient clinic and another 8 patients were implanted in the operating room. All office procedures were done under local anesthesia; operating room procedures used either general anesthesia or intravenous sedation. Follow-up occurred over 12 months. Time required, cost of the procedure, and other logistical concerns between operating room and office-based insertion were evaluated and compared. RESULTS: When performed in the office, patient fees were reduced by 31%, and patient time investment was reduced 73%. Physician time was reduced by 50%. After office-based insertion, patients were able to return to their normal routine immediately after the procedure, and no chaperone or designated driver was required. No infection or complications occurred in either group. CONCLUSION: Bone-anchored Hearing Aid insertion in the clinic setting is safe and cost-effective, saving the patient and physician significant time and resources.

Diagnosis and management of lateral semicircular canal benign paroxysmal positional vertigo.

OBJECTIVE: Describe the diagnosis, treatment, and outcome of a group of 20 patients with lateral semicircular canal benign paroxysmal positional vertigo (LSC-BPPV). STUDY DESIGN AND SETTING: Retrospective review of 20 patients with LSC-BPPV (10 with geotropic and 10 with apogeotropic nystagmus) presenting to a tertiary balance center. Diagnosis was confirmed with infrared nystagmography in Dix-Hallpike positioning tests and supine positional tests. Patients were treated with one or more particle repositioning maneuvers. RESULTS: Addition of supine positional nystagmus tests to Dix-Hallpike positioning testing improves sensitivity in the diagnosis of LSC-BPPV. Treatment outcomes in the apogeotropic LSC-BPPV group were poorer than the geotropic LSC-BPPV group. SIGNIFICANCE: Adding supine positional testing to routine vestibular diagnostic testing will increase the identification of LSC-BPPV. Apogeotropic LSC-BPPV is more challenging to treat.