Diagnostic value of vestibular evoked myogenic potentials in benign paroxysmal positional vertigo.

OBJECTIVES: Vestibular evoked myogenic potentials (VEMPs) are useful for studying the disturbances along nerve pathways implicated in the transmission of neurological information from otolithic organs related to vestibular function. This study aims to determine the differences in VEMPs in patients affected with benign paroxysmal positional vertigo (BPPV). METHODS: We recruited 36 patients, 9 diagnosed with recurrent BPPV (rBPPV), 9 with only one episode of vertigo (iBPPV), and 18 as a control group. We performed cervical and ocular VEMPs (cVEMPs and oVEMPs). RESULTS: We observed differences in asymmetry ratio, which was 41.82% in cVEMPs in iBPPV and 68.27% in oVEMPs in rBPPV, while no asymmetry was found in control cases. Also, there was a lack of both VEMP responses in 22.2% of cases and an absence of cVEMP in 11.1% in iBPPV; in rBPPV, 11.1 % presented no responses in cVEMPs or oVEMPs, 22.2% showed no oVEMP, and 11.1% showed no cVEMP. These values were normal in the control group. CONCLUSION: The value of VEMPs in BPPV demonstrates the implication of vestibular damage, mainly utricle damage. For better sensitivity in detecting otolith abnormalities, we should perform oVEMPs and cVEMPs in recurrent BPPV and early stages of BPPV.

A novel maneuver for diagnosis and treatment of torsional-vertical down beating positioning nystagmus: anterior canal and apogeotropic posterior canal BPPV / Uma nova manobra para diagnóstico e tratamento de nistagmo vertical para baixo com componente de torção: forma apogeotrópica da VPPB do canal anterior e canal posterior

Abstract Introduction In patients with benign paroxysmal positional vertigo, BPPV; a torsional-vertical down beating positioning nystagmus can be elicited in the supine straight head-hanging position test or in the Dix-Hallpike test to either side. This type of nystagmus can be explained by either an anterior canal BPPV or by an apogeotropic variant of the contralateral posterior canal BPPV Until now all the therapeutic maneuvers that have been proposed address only one possibility, and without first performing a clear differential diagnosis between them. Objective To propose a new maneuver for torsional-vertical down beating positioning nystagmus with a clear lateralization that takes into account both possible diagnoses (anterior canal-BPPV and posterior canal-BPPV). Methods A prospective cohort study was conducted on 157 consecutive patients with BPPV. The new maneuver was performed only in those with torsional-vertical down beating positioning nystagmus with clear lateralization. Results Twenty patients (12.7%) were diagnosed with a torsional-vertical down beating positioning nystagmus. The maneuver was performed in 10 (6.35%) patients, in whom the affected side was clearly determined. Seven (4.45%) patients were diagnosed with an anterior canal-BPPV and successfully treated. Two (1.25%) patients were diagnosed with a posterior canal-BPPV and successfully treated with an Epley maneuver after its conversion into a geotropic posterior BPPV. Conclusion This new maneuver was found to be effective in resolving all the cases of torsional-vertical down beating positioning nystagmus-BPPV caused by an anterior canal-BPPV, and in shifting in a controlled way the posterior canal-BPPV cases of the contralateral side into a geotropic-posterior-BPPV successfully treated during the followup visit. Moreover, this new maneuver helped in the differential diagnosis between anterior canal-BPPV and a contralateral posterior canal-BPPV.

Resumo Introdução Em pacientes com vertigem posicional paroxística benigna, VPPB, um nistagmo vertical para baixo com componente de torção pode ser provocado no teste head hanging supino executado na posição reta ou no teste de Dix-Hallpike para qualquer um dos lados. Esse tipo de nistagmo pode ser explicado por uma VPPB do canal anterior ou por uma variante apogeotrópica da VPPB do canal posterior contralateral. Até agora, todas as manobras terapêuticas propostas abordam apenas uma possibilidade, sem antes fazer um diagnóstico diferencial claro entre elas. Objetivo Propor uma nova manobra para nistagmo vertical para baixo com componente de torção com uma lateralização clara que leve em consideração os dois diagnósticos possíveis, VPPB do canal anterior e VPPB do canal posterior. Método Um estudo de coorte prospectivo foi conduzido em 157 pacientes consecutivos com VPPB. A nova manobra foi feita apenas nos pacientes com nistagmo vertical para baixo com componente de torção, com lateralização nítida. Resultados Vinte pacientes (12,7%) foram diagnosticados com nistagmo vertical para baixo com componente de torção. A manobra foi feita em 10 (6,35%) pacientes, nos quais o lado afetado foi claramente determinado. Sete (4,45%) pacientes foram diagnosticados com VPPB do canal anterior e tratados com sucesso. Dois (1,25%) pacientes foram diagnosticados com VPPB do canal posterior e tratados com sucesso com a manobra de Epley após sua conversão para VPPB geotrópica de canal posterior. Conclusão Essa nova manobra mostrou-se eficaz na resolução de todos os casos de VPPB com nistagmo vertical para baixo com componente de torção causada por VPPB do canal anterior. E na mudança de forma controlada dos casos de VPPB do canal posterior do lado contralateral para uma VPPB geotrópica de canal posterior tratada com sucesso durante a consulta de seguimento. Além disso, essa nova manobra auxiliou no diagnóstico diferencial entre a VPPB do canal anterior e a VPPB do canal posterior contralateral.

Comparative Analysis of the Efficiency of Two Treatment Protocols for Posterior Canal Benign Paroxysmal Positional Vertigo.

BACKGROUND AND OBJECTIVE: Benign paroxysmal positional vertigo (BPPV) is the most common vertigo of labyrinthine origin, its social and healthcare impact is remarkable. It has recently been shown that single session treatment is as safe and effective as weekly treatment, which could have impact on direct and indirect costs related to the disease. The objective of this study is to determine whether single session treatment of unilateral posterior canal BPPV canalolithiasis is more efficient than conventional treatment. MATERIALS AND METHODS: A prospective randomized controlled trial was performed in 53 consecutive patients diagnosed with unilateral posterior canal BPPV canalolithiasis previously untreated: 26 patients were assigned to single session treatment and 27 patients to weekly treatment. Average and total cost of care, consultation time and the impact in terms of temporary disability and loss of productivity for the company due to patients' medical visits were compared. RESULTS: Average and total cost of care and loss of productivity for the company due to patients' medical visits were significantly lower in the single session group. Consultation time was also better in this group when travelling time was considered. CONCLUSIONS: The single session protocol is fast, effective and reduces direct and indirect cost of care related to disease justifying high resolution consultations.

Análisis comparativo de la eficiencia de dos protocolos de tratamiento del vértigo posicional paroxístico benigno del conducto semicircular posterior / Comparative Analysis of the Efficiency of Two Treatment Protocols for Posterior Canal Benign Paroxysmal Positional Vertigo

Antecedentes y objetivo: El vértigo posicional paroxístico benigno (VPPB) es la causa más frecuente de vértigo de origen laberíntico; su impacto social y en términos de cuidados de salud es notable. Recientemente se ha demostrado que es clínicamente posible realizar el tratamiento y su comprobación en la misma sesión, lo cual podría tener repercusión en los costes asistenciales directos e indirectos relacionados con la enfermedad. El objetivo de este trabajo es determinar si el protocolo de tratamiento unisesión del VPPB CP unilateral tipo conductolitiasis es más eficiente que el protocolo de tratamiento convencional. Materiales y métodos: Estudio prospectivo controlado y aleatorizado en 53 pacientes consecutivos diagnosticados de un VPPB CP unilateral tipo conductolitiasis no tratados previamente; 26 pacientes fueron asignados al grupo unisesión y 27 al semanal clásico. Se compararon los costes medio y total de la asistencia, el tiempo de consulta y el impacto en términos de incapacidad temporal y pérdida de productividad para la empresa asociada a la visita médica del paciente. Resultados: Los costes medio y total de la asistencia así como la pérdida de productividad para una empresa asociada a la visita médica de los pacientes laboralmente activos fueron significativamente menores en el protocolo unisesión. También el tiempo de consulta cuando se consideró el tiempo de desplazamiento al centro. Conclusiones: El protocolo de tratamiento unisesión es rápido, efectivo y reduce los costes asistenciales directos e indirectos relacionados con la enfermedad justificando consultas de alta resolución. (AU)

Background and objective: Benign paroxysmal positional vertigo (BPPV) is the most common vertigo of labyrinthine origin, its social and healthcare impact is remarkable. It has recently been shown that single session treatment is as safe and effective as weekly treatment, which could have impact on direct and indirect costs related to the disease. The objective of this study is to determine whether single session treatment of unilateral posterior canal BPPV canalolithiasis is more efficient than conventional treatment. Materials and methods: A prospective randomized controlled trial was performed in 53 consecutive patients diagnosed with unilateral posterior canal BPPV canalolithiasis previously untreated: 26 patients were assigned to single session treatment and 27 patients to weekly treatment. Average and total cost of care, consultation time and the impact in terms of temporary disability and loss of productivity for the company due to patients’ medical visits were compared. Results: Average and total cost of care and loss of productivity for the company due to patients’ medical visits were significantly lower in the single session group. Consultation time was also better in this group when travelling time was considered. Conclusions: The single session protocol is fast, effective and reduces direct and indirect cost of care related to disease justifying high resolution consultations. (AU)

Lateral semicircular canal-BPPV: Prospective randomized study on the efficacy of four repositioning maneuvers.

INTRODUCTION: Multiple repositioning maneuvers have been described to treat lateral semi-circular canal Benign Paroxysmal Positional Vertigo (LC-BPPV) patients. In this study, we compare efficacy of four therapeutic repositioning maneuvers for LC-BPPV patients and aim to identify clinical variables associated with persistent disease. MATERIAL AND METHODS: A prospective study was conducted at a tertiary center, between January 2017 and September 2019. Patients diagnosed with LC-BPPV were randomly treated with Gufoni or barbecue-roll maneuvers (for the geotropic variant) and Gufoni-Appiani, barbecue-roll or Zuma-e-Maia maneuvers (for the apogeotropic form). Efficacy was compared and statistical analysis was performed to find clinical factors associated with no response. RESULTS: Forty-eight patients and 82 maneuvers were included. Female patients and right side were more commonly affected. The mean age was 67 years. Seven cases (14.6%) resulted from a canal-switch. One single maneuver resolved 23 cases (47.9%) and the success rate rose to 75% at the end of the first visit (after up to 4 maneuvers) and to 93.8% after a-week of follow-up. Success rates were significantly better with Gufoni (68%) than with barbecue roll (34.8%; p=0.021) in geotropic LC-BPPV and better with Gufoni-Appiani (71.4%) than barbecue roll and Zuma-e-Maia maneuvers (33.3%; p=0.239) in apogeotropic LC-BPPV. Higher rates of persistent disease after first visit were found with older patients, left side and apogeotropic LC-BPPV and with longer latency and duration diagnostic nystagmus. CONCLUSION: Our study suggests that Gufoni and Gufoni-Appiani maneuvers may be the most efficacious treatment for geotropic and apogeotropic LC-BPPV, respectively, compared to barbecue-roll and Zuma-e-Maia maneuvers.

VPPB del canal semicircular lateral: estudio prospectivo aleatorizado de la eficacia de 4 maniobras de reposicionamiento / Lateral semicircular canal-BPPV: Prospective randomized study on the efficacy of four repositioning maneuvers

Introduction: Multiple repositioning maneuvers have been described to treat lateral semi-circular canal Benign Paroxysmal Positional Vertigo (LC-BPPV) patients. In this study, we compare efficacy of four therapeutic repositioning maneuvers for LC-BPPV patients and aim to identify clinical variables associated with persistent disease. Material and methods: A prospective study was conducted at a tertiary center, between January 2017 and September 2019. Patients diagnosed with LC-BPPV were randomly treated with Gufoni or barbecue-roll maneuvers (for the geotropic variant) and Gufoni-Appiani, barbecue-roll or Zuma-e-Maia maneuvers (for the apogeotropic form). Efficacy was compared and statistical analysis was performed to find clinical factors associated with no response. Results: Forty-eight patients and 82 maneuvers were included. Female patients and right side were more commonly affected. The mean age was 67 years. Seven cases (14.6%) resulted from a canal-switch. One single maneuver resolved 23 cases (47.9%) and the success rate rose to 75% at the end of the first visit (after up to 4 maneuvers) and to 93.8% after a-week of follow-up. Success rates were significantly better with Gufoni (68%) than with barbecue roll (34.8%; p=0.021) in geotropic LC-BPPV and better with Gufoni-Appiani (71.4%) than barbecue roll and Zuma-e-Maia maneuvers (33.3%; p=0.239) in apogeotropic LC-BPPV. Higher rates of persistent disease after first visit were found with older patients, left side and apogeotropic LC-BPPV and with longer latency and duration diagnostic nystagmus. Conclusion: Our study suggests that Gufoni and Gufoni-Appiani maneuvers may be the most efficacious treatment for geotropic and apogeotropic LC-BPPV, respectively, compared to barbecue-roll and Zuma-e-Maia maneuvers. (AU)

Introducción: Se han descrito múltiples maniobras de reposicionamiento para tratar a los pacientes con vértigo postural paroxístico benigno del canal semicircular lateral (VPPB-CSL). En este estudio comparamos la eficacia de 4 maniobras de reposicionamiento terapéutico para pacientes de BPPV-CSL, con el objetivo de identificar las variables clínicas asociadas a la persistencia de la enfermedad. Material y métodos: Se realizó un estudio prospectivo en un centro terciario, entre enero de 2017 y septiembre de 2019. Se trató aleatoriamente a los pacientes diagnosticados de VPPB-CSL con las maniobras de Gufoni o Barbecue-Roll (para la variante geotrópica) y las maniobras de Gufoni-Appiani, Barbecue-Roll o Zuma-e-Maia (para la forma apogeotrópica), comparándose su eficacia y realizándose un análisis estadístico para encontrar los factores clínicos asociados a la falta de respuesta. Resultados: El estudio incluyó 48 pacientes y 82 maniobras. Las mujeres y el lado derecho fueron los más comúnmente afectados. La edad media fue de 67 años. Siete casos (14,6%) fueron resultado de un fenómeno de reentrada. Una única maniobra resolvió 23 casos (47,9%), elevándose la tasa de éxito al 75% al finalizar la primera visita (tras un máximo de 4 maniobras) y al 93,8% tras una semana de seguimiento. Las tasas de éxito fueron significativamente más altas con la maniobra de Gufoni (68%) en comparación con la de Barbecue-Roll (34,8%; p=0,021) en VPPB-CSL geotrópico, y también fueron más altas con las maniobras de Gufoni-Appiani (71,4%) en comparación con las de Barbecue-Roll y Zuma-e-Maia (33,3%; p=0,239) en VPPB-CSL apogeotrópico. Las tasas más altas de persistencia de la enfermedad tras la primera visita se encontraron en pacientes mayores, lado izquierdo y VPPB-CSL apogeotrópica, con mayor latencia y duración del nistagmo diagnóstico. (AU)

Clinical characteristics of patients with multi-canal benign paroxysmal positional vertigo / Características clínicas de pacientes com vertigem posicional paroxística benigna multicanal

Abstract Introduction Multi-canal benign paroxysmal positional vertigo is considered to be a rare and controversial type in the new diagnostic guidelines of Bárány because the nystagmus is more complicated or atypical, which is worthy of further study. Objective Based on the diagnostic criteria for multi-canal benign paroxysmal positional vertigo proposed by International Bárány Society, the study aimed to investigate the clinical characteristics, diagnosis and treatment of multi-canal benign paroxysmal positional vertigo. Methods A total of 41 patients with multi-canal benign paroxysmal positional vertigo were included and diagnosed by Roll, Dix-Hallpike and straight head hanging tests. Manual reduction was performed according to the involvement of semicircular canals. Results Among the 41 cases, 19 (46.3%) patients showed vertical up-beating nystagmus with or without torsional component and geotropic, apogeotropic horizontal nystagmus, and were diagnosed with posterior-horizontal canal. 11 (26.8%) patients showed vertical up-beating nystagmus with torsional component on one side and vertical down-beating nystagmus with or without torsional component on the other side during Dix-Hallpike test or straight head hanging test and were diagnosed with posterior-anterior canal benign paroxysmal positional vertigo 9 (26.8%) patients showed vertical down-beating nystagmus with or without torsional component and geotropic, apogeotropic horizontal nystagmus, and were diagnosed with anterior-horizontal canal 2 (4.9%) patients showed vertical geotropic torsional up-beating nystagmus on both sides and were diagnosed with bilateral posterior canal benign paroxysmal positional vertigo. High correlation between the sides with reduced vestibular function or hearing loss and the side affected by Multi-canal benign paroxysmal positional vertigo was revealed (contingency coefficient = 0.602, p = 0.010). During one-week follow up, nystagmus/vertigo has been significantly alleviated or disappeared in 87.8% (36/41) patients. Conclusion Posterior-horizontal canal benign paroxysmal positional vertigo was the most common type. Multi-canal benign paroxysmal positional vertigo involving anterior canal was also not uncommon. Caloric tests and pure tone audiometry may help in the determination of the affected side. Manual reduction was effective in most of Multi-canal benign paroxysmal positional vertigo patients.

Resumo Introdução A vertigem posicional paroxística benigna multicanal é considerada um tipo raro e controverso nas novas diretrizes de diagnóstico da Bárány Society, porque o nistagmo é mais complicado ou atípico, o que é digno de mais estudos. Objetivo Com base nos critérios diagnósticos para a vertigem posicional paroxística benigna multicanal proposta pela International Bárány Society, o estudo teve como objetivo investigar as características clínicas, o diagnóstico e o tratamento da vertigem posicional paroxística benigna multicanal. Método Foram incluídos 41 pacientes com vertigem posicional paroxística benigna multicanal e diagnosticados pelo teste de Dix-Hallpike, roll test ou e teste straight head hanging A redução manual foi feita de acordo com o envolvimento dos canais semicirculares. Resultados Entre os 41 casos, 19 (46,3%) pacientes apresentaram nistagmo de batimento ascendente vertical com ou sem componente de torção e nistagmo horizontal apogeotrópico e geotrópico e foram diagnosticados com vertigem posicional paroxística benigna de canal horizontal-posterior. Onze (26,8%) pacientes apresentaram nistagmo vertical de batimento ascendente com componente de torção de um lado e nistagmo vertical de batimento descendente com ou sem componente de torção do outro lado durante o teste de Dix-Hallpike ou teste straight head hanging e foram diagnosticados com vertigem posicional paroxística benigna do canal posterior-anterior. Nove (26,8%) pacientes apresentaram nistagmo vertical com batimento descendente com ou sem componente de torção e nistagmo horizontal apogeotrópico e geotrópico e foram diagnosticados com vertigem posicional paroxística benigna de canal anterior-horizontal. Dois (4,9%) pacientes apresentaram nistagmo de torção geotrópico vertical de batimento ascendente em ambos os lados e foram diagnosticados com vertigem posicional paroxística benigna de canal posterior bilateral. Foi revelada alta correlação entre os lados com função vestibular reduzida ou perda auditiva e o lado afetado pela vertigem posicional paroxística benigna multicanal (coeficiente de contingência = 0,602, p = 0,010). Durante o seguimento de uma semana, o nistagmo/vertigem foi significativamente aliviado ou desapareceu em 87,8% (36/41) dos pacientes. Conclusões A vertigem posicional paroxística benigna de canal horizontal e posterior foi o tipo mais comum. A vertigem posicional paroxística benigna multicanal que envolveu canal anterior também não foi incomum. Testes calóricos e audiometria tonal pura podem ajudar na determinação do lado afetado. A redução manual foi eficaz na maioria dos pacientes com vertigem posicional paroxística benigna multicanal.

Lateral semicircular canal-BPPV: Prospective randomized study on the efficacy of four repositioning maneuvers.

INTRODUCTION: Multiple repositioning maneuvers have been described to treat lateral semi-circular canal Benign Paroxysmal Positional Vertigo (LC-BPPV) patients. In this study, we compare efficacy of four therapeutic repositioning maneuvers for LC-BPPV patients and aim to identify clinical variables associated with persistent disease. MATERIAL AND METHODS: A prospective study was conducted at a tertiary center, between January 2017 and September 2019. Patients diagnosed with LC-BPPV were randomly treated with Gufoni or barbecue-roll maneuvers (for the geotropic variant) and Gufoni-Appiani, barbecue-roll or Zuma-e-Maia maneuvers (for the apogeotropic form). Efficacy was compared and statistical analysis was performed to find clinical factors associated with no response. RESULTS: Forty-eight patients and 82 maneuvers were included. Female patients and right side were more commonly affected. The mean age was 67 years. Seven cases (14.6%) resulted from a canal-switch. One single maneuver resolved 23 cases (47.9%) and the success rate rose to 75% at the end of the first visit (after up to 4 maneuvers) and to 93.8% after a-week of follow-up. Success rates were significantly better with Gufoni (68%) than with barbecue roll (34.8%; p=0.021) in geotropic LC-BPPV and better with Gufoni-Appiani (71.4%) than barbecue roll and Zuma-e-Maia maneuvers (33.3%; p=0.239) in apogeotropic LC-BPPV. Higher rates of persistent disease after first visit were found with older patients, left side and apogeotropic LC-BPPV and with longer latency and duration diagnostic nystagmus. CONCLUSION: Our study suggests that Gufoni and Gufoni-Appiani maneuvers may be the most efficacious treatment for geotropic and apogeotropic LC-BPPV, respectively, compared to barbecue-roll and Zuma-e-Maia maneuvers.

Comparative analysis of the efficiency of two treatment protocols for posterior canal benign paroxysmal positional vertigo. / Análisis comparativo de la eficiencia de dos protocolos de tratamiento del vértigo posicional paroxístico benigno del conducto semicircular posterior.

BACKGROUND AND OBJECTIVE: Benign paroxysmal positional vertigo (BPPV) is the most common vertigo of labyrinthine origin, its social and healthcare impact is remarkable. It has recently been shown that single session treatment is as safe and effective as weekly treatment, which could have impact on direct and indirect costs related to the disease. The objective of this study is to determine whether single session treatment of unilateral posterior canal BPPV canalolithiasis is more efficient than conventional treatment. MATERIALS AND METHODS: A prospective randomized controlled trial was performed in 53 consecutive patients diagnosed with unilateral posterior canal BPPV canalolithiasis previously untreated: 26 patients were assigned to single session treatment and 27 patients to weekly treatment. Average and total cost of care, consultation time and the impact in terms of temporary disability and loss of productivity for the company due to patients' medical visits were compared. RESULTS: Average and total cost of care and loss of productivity for the company due to patients' medical visits were significantly lower in the single session group. Consultation time was also better in this group when travelling time was considered. CONCLUSIONS: The single session protocol is fast, effective and reduces direct and indirect cost of care related to disease justifying high resolution consultations.

Subjective benign paroxysmal positional vertigo in patients with osteoporosis or migraine / Vertigem posicional paroxística benigna subjetiva em pacientes com osteoporose ou migrânea

Abstract Introduction Subjective benign paroxysmal positional vertigo is a form of benign paroxysmal positional vertigo in which during the diagnostic positional maneuvers patients only present vertigo symptoms with no nystagmus. Objective To study the characteristics of subjects with subjective benign paroxysmal positional vertigo. Methods Prospective multicenter case-control study. All patients presenting with vertigo in the Dix-Hallpike test that presented to the participating hospitals were included. The patients were separated into two groups depending on whether nystagmus was present or not. An Epley Maneuver of the affected side was performed. In the follow-up visit, patients were checked to see if nystagmus and vertigo were present. Both groups of patients were compared to assess the success rate of the Epley maneuver and also to compare the presence of 19 variables. Results 259 patients were recruited, of which 64 belonged to the subjective group. Nystagmus was eliminated in 67.2% of the patients with benign paroxysmal positional vertigo. 89.1% of the patients with subjective benign paroxysmal positional vertigo remained unaffected by nystagmus, thus showing a significant difference (p = 0.001). Osteoporosis and migraine were the variables which reached the closest to the significance level. In those patients who were taking vestibular suppressors, the percentage of subjective benign paroxysmal positional vertigo was not significantly higher. Conclusions Subjective benign paroxysmal positional vertigo should be treated using the Epley maneuver. More studies are needed to establish a relationship between osteoporosis, migraine and subjective benign paroxysmal positional vertigo. The use of vestibular suppressants does not affect the detection of nystagmus.

Resumo Introdução A vertigem posicional paroxística benigna subjetiva é um tipo de vertigem posicional paroxística benigna na qual, durante as manobras posicionais diagnósticas, os pacientes apresentam apenas sintomas vertiginosos sem nistagmo. Objetivo Estudar as características de indivíduos com vertigem posicional paroxística benigna subjetiva. Método Estudo prospectivo multicêntrico de caso-controle. Foram incluídos todos os pacientes com vertigem no teste de Dix-Hallpike, que se apresentaram nos hospitais participantes. Os pacientes foram separados em dois grupos, dependeu da presença ou não do nistagmo. Uma manobra de Epley foi realizada no lado afetado. Na consulta de seguimento, os pacientes foram avaliados para verificar a presença ou não do nistagmo e da vertigem. Ambos os grupos de pacientes foram comparados para avaliar a taxa de sucesso da manobra de Epley e também para comparar a presença de 19 variáveis. Resultados Foram recrutados 259 pacientes, dos quais 64 pertenciam ao grupo subjetivo. O nistagmo foi eliminado em 67,2% dos pacientes com vertigem posicional paroxística benigna. Em 89,1% dos casos, os pacientes com vertigem posicional paroxística benigna subjetiva mantiveram-se não afetados pelo nistagmo, mostraram uma diferença significativa (p = 0,001). Osteoporose e enxaqueca foram as variáveis que atingiram o nível mais próximo ao de significância. Nos pacientes que tomavam supressores vestibulares, a porcentagem de vertigem posicional paroxística benigna subjetiva não foi significativamente maior. Conclusões A vertigem posicional paroxística benigna subjetiva deve ser tratada com a manobra de Epley. Mais estudos são necessários para estabelecer uma relação entre osteoporose, enxaqueca e vertigem posicional paroxística benigna subjetiva. O uso de supressores vestibulares não afeta a detecção do nistagmo.

Subjective benign paroxysmal positional vertigo in patients with osteoporosis or migraine.

INTRODUCTION: Subjective benign paroxysmal positional vertigo is a form of benign paroxysmal positional vertigo in which during the diagnostic positional maneuvers patients only present vertigo symptoms with no nystagmus. OBJECTIVE: To study the characteristics of subjects with subjective benign paroxysmal positional vertigo. METHODS: Prospective multicenter case-control study. All patients presenting with vertigo in the Dix-Hallpike test that presented to the participating hospitals were included. The patients were separated into two groups depending on whether nystagmus was present or not. An Epley Maneuver of the affected side was performed. In the follow-up visit, patients were checked to see if nystagmus and vertigo were present. Both groups of patients were compared to assess the success rate of the Epley maneuver and also to compare the presence of 19 variables. RESULTS: 259 patients were recruited, of which 64 belonged to the subjective group. Nystagmus was eliminated in 67.2% of the patients with benign paroxysmal positional vertigo. 89.1% of the patients with subjective benign paroxysmal positional vertigo remained unaffected by nystagmus, thus showing a significant difference (p=0.001). Osteoporosis and migraine were the variables which reached the closest to the significance level. In those patients who were taking vestibular suppressors, the percentage of subjective benign paroxysmal positional vertigo was not significantly higher. CONCLUSIONS: Subjective benign paroxysmal positional vertigo should be treated using the Epley maneuver. More studies are needed to establish a relationship between osteoporosis, migraine and subjective benign paroxysmal positional vertigo. The use of vestibular suppressants does not affect the detection of nystagmus.

Evaluación inicial del paciente con mareos y vértigo / Initial evaluation of the patient with dizziness and vertigo

El paciente que consulta por mareos o vértigo es sin duda un desafío para el médico que trabaja en un servicio de urgencia. Esto se da en parte por la dificultad de los pacientes de definir el síntoma, a la amplia gama de diagnósticos diferenciales y su potencial riesgo de desenlace negativo, como en el caso del accidente cerebrovascular de fosa posterior. En esta revisión narrativa, el objetivo: es explicar el enfrentamiento inicial del paciente con mareos y vértigo, describir las pruebas y métodos diagnósticos complementarios, distinguir los diagnósticos diferenciales más frecuentes y explicar el manejo inicial. Método:se realizó una revisión bibliográfica de literatura científica sobre esta patología, basado en la propuesta de Edlow (2016), donde se enfatiza en un enfoque basado en temporalidad, factores desencadenantes y contexto del síntoma.(AU)

The patient who consults for dizziness or vertigo is undoubtedly a challenge for the emergency physician. This is partly due to the difficulty of the patients to define the symptom, the wide range of differential diagnoses and their potential risk of negative outcome, as in the case of posterior circulation stroke. In this narrative review, the objective is to explain the initial approach of the patient with dizziness and vertigo, describe the tests and complementary diagnostic methods, distinguish the most frequent differential diagnoses and explain the initial management. A bibliographic review of the scientific literature on this pathology was carried out, based on the proposal of Edlow (2016), which emphasizes an approach based on temporality, trigger factors and context of the symptom. (AU)

Impacto de las Maniobras de Reposicionamiento en el grado de discapacidad de pacientes con Vértigo Posicional Paroxístico Benigno del conducto semicircular posterior

Introducción. El Vértigo Posicional Paroxístico Benigno (VPPB) del canal semicircular posterior es una enfermedad crónica que afecta severamente la calidad de vida de los pacientes que lo sufren. Para su manejo existen las Maniobras de Reposicionamiento, que son una serie de ejercicios secuenciales de la cabeza en 4 posiciones. El propósito de la maniobra es reposicionar los otolitos desde el conducto semicircular posterior dentro del vestíbulo a los sitios de donde migraron para dejar de producir vértigo. Permaneciendo en cada posición aproximadamente 30 segundos. Las maniobras han demostrado gran eficacia a corto plazo. Los resultados son medibles por medio de un cuestionario conocido como Dizziness Handicap Inventory (DHI). Objetivos: Medir el impacto de las maniobras de reposicionamiento en la discapacidad en los pacientes con Vértigo Posicional Paroxístico Benigno del conducto semicircular posterior, mediante el uso del DHI. Metodología. Es un estudio comparativo que utiliza la T de Student para muestras pareadas donde cada paciente es su propio control, se tomó una muestra de 20 pacientes diagnosticados con Vértigo Posicional Paroxístico Benigno del conducto semicircular posterior que serán tratados con maniobras de reposicionamiento, serán evaluados mediante la herramienta (DHI) que será completada por los pacientes al inicio del estudio, al día 7 y día 30, luego de realizadas las Maniobras de Reposicionamiento. Resultados: Las mujeres son las más afectadas por el (VPPB) del canal semicircular posterior en una relación de 2.1 aproximadamente. El grado de discapacidad fue medido por el resultado del DHI, el cual muestra para los días 1, 7, y 30 una media de 50.4, 30.4 y 24.2 respectivamente. La escala con mayor punteo durante los días 1, 7, y 30 fue la escala funcional mostrando una media de 20, 12.2, y 9.5 respectivamente. Las diferencias entre las medias fueron estadísticamente significativas. (p= 0.00006, 0.000002 y 0.03701). Conclusiones: El padecimiento de VPPB del conducto semicircular posterior afecta la calidad en el estilo de vida de las personas. Las maniobras de reposicionamiento son estadísticamente significativas para disminuir la incapacidad generada por el vértigo posicional paroxístico benigno del conducto semicircular posterior por lo que es importante acudir rápidamente al médico especialista cuando se manifiesten los primeros signos y evitar así aumentar la discapacidad total asociada al vértigo. Palabras Clave: Vértigo Posicional Paroxístico (VPPB), otolitos, Dizziness Handycap Inventory (DHI).

Introduction. Benign Paroxysmal Positional Vertigo (BPPV) of the posterior semicircular canal is a chronic disease severely affecting quality of life. Repositioning Maneuvers is a way of relieving it, consisting of a series of sequential exercises of the head into 4 positions. The purpose of the maneuver is to reposition the otoliths from the posterior semicircular canal inside the lobby to the sites where they migrated to stop producing vertigo. Each position has to remain for approximately 30 seconds. The maneuvers have proven to be highly effective in the short term. The results are measurable by means of a questionnaire known as Dizziness Handicap Inventory (DHI). Objectives: To measure the impact of repositioning maneuvers on disability in patients with BPPV of posterior semicircular canal, using the DHI. Methods: A comparative study using T-test for paired samples where each patient is his own control was used in a sample of 20 patients diagnosed with BPPV of posterior semicircular canal were studied and treated with repositioning maneuvers. Results were evaluated by DHI and ran in day 1, day 7 and 30 after Repositioning maneuvers performed. Results: Females are most affected by BPPV in a ratio of approximately 2.1. The degree of disability was measured by the result of DHI, which shows for days 1, 7, and 30 an average of 50.4, 30.4 and 24.2 respectively. The scale with a higher score were days 1 and 7 then showing a marked decreased on day 30. Mean results were the 20, 12.2 and 9.5 respectively. The differences between the means were statistically significant. (P = 0.000062, 0.000002 and 0.037010). Conclusions: BPPV affects the quality of life. Repositioning maneuvers are statistically significant to reduce the disability caused by BPPV of the posterior semicircular canal so, it is important to quickly see a specialist when first signs manifest and that way avoid increasing the total disability associated with vertigo. Keywords: Paroxysmal Positional Vertigo (BPPV), Otolith, Dizziness Handicap Inventory (DHI)

Clínica, diagnóstico y terapéutica del vértigo posicional paroxístico benigno / Benign paroxysmal positional vertigo: clinical diagnosis and treatment

Benign paroxysmal positional vertigo is the most common vestibular disorder and it has a significant impact in health-related quality of life. The disease is probably caused by the accumulation of lithiasis material from the otolithic membrane of the utricle. Patients experience multiple short crises of vertigo lasting seconds when they lay or turn in bed. There are several clinical variants affecting posterior, horizontal or anterior canal and in some cases vestibular lithiasis can occur in two canals simultaneously. The diagnosis is performed by video-oculographic recording of positional nystagmus during positional testing to identify the canal affected. There are specific treatment maneuvers for each clinical variant, which are highly effective at short term

El vértigo posicional paroxístico benigno es el trastorno vestibular más frecuente y tiene un impacto significativo sobre la calidad de vida relacionada con la salud. La enfermedad se origina probablemente por la acumulación de un material litiásico procedente de la membrana otolítica del utrículo. Los pacientes sufren múltiples crisis de vértigo cortas que duran segundos cuando se acuestan o se dan la vuelta en la cama. Existen varias formas clínicas que pueden afectar los conductos posterior, horizontal o anterior y que en algunos casos afectan dos conductos simultáneamente. El diagnóstico se realiza mediante el registro videooculográfico del nistagmo posicional al realizar las pruebas posicionales para localizar el conducto afectado. Existen maniobras terapeúticas específicas para cada variante clínica, las cuales presentan una elevada efectividad a corto plazo