Pseudo-spontaneous nystagmus in patients with lateral canal benign paroxysmal positional vertigo.

BACKGROUND: Pseudo-spontaneous nystagmus (PSN) can be detected in patients with lateral canal benign paroxysmal positional vertigo (LC-BPPV). Its frequency, and correlation with the therapeutic outcome have been less described and conflicting results have been reported. OBJECTIVE: This study aims to investigate its clinical and prognostic significance. MATERIAL AND METHOD: One hundred and eighty-four patients with LC BPPV (98 apogeotropic, 86 geotropic type) were enrolled for the study. Clinical parameters were reviewed in patients with or without PSN. The Chi-square and one way ANOVA tests were used to compare the difference between study groups. Statistical significance was set at p < .05. RESULTS: Twenty-two patients with apogeotropic (22.4%; 98/22) and 17 patients with geotropic nystagmus (19.7%; 86/17) had PSN. The incidence, age, male-female ratio, mean slow phase velocity (SPV), duration of BPPV and the rate of recurrence were not significant in patients with LC-BPPV whether they have PSN or not. CONCLUSION: Prognostic role of PSN in patients with LC BPPV seems to be questionable. SIGNIFICANCE: Appearance and disappearance of PSN with regard to head position helps to differentiate BPPV from other acute vestibular disorders. Additionally, direction of nystagmus assists to determine the site of the affected canal. However, prognostic significance is obscure.

Walking stability in patients with benign paroxysmal positional vertigo: an objective assessment using wearable accelerometers and machine learning.

BACKGROUND: Benign paroxysmal positional vertigo (BPPV) is one of the most common peripheral vestibular disorders leading to balance difficulties and increased fall risks. This study aims to investigate the walking stability of BPPV patients in clinical settings and propose a machine-learning-based classification method for determining the severity of gait disturbances of BPPV. METHODS: Twenty-seven BPPV outpatients and twenty-seven healthy subjects completed level walking trials at self-preferred speed in clinical settings while wearing two accelerometers on the head and lower trunk, respectively. Temporo-spatial variables and six walking stability related variables [root mean square (RMS), harmonic ratio (HR), gait variability, step/stride regularity, and gait symmetry] derived from the acceleration signals were analyzed. A support vector machine model (SVM) based on the gait variables of BPPV patients were developed to differentiate patients from healthy controls and classify the handicapping effects of dizziness imposed by BPPV. RESULTS: The results showed that BPPV patients employed a conservative gait and significantly reduced walking stability compared to the healthy controls. Significant different mediolateral HR at the lower trunk and anteroposterior step regularity at the head were found in BPPV patients among mild, moderate, and severe DHI (dizziness handicap inventory) subgroups. SVM classification achieved promising accuracies with area under the curve (AUC) of 0.78, 0.83, 0.85 and 0.96 respectively for differentiating patients from healthy controls and classifying the three stages of DHI subgroups. Study results suggest that the proposed gait analysis that is based on the coupling of wearable accelerometers and machine learning provides an objective approach for assessing gait disturbances and handicapping effects of dizziness imposed by BPPV.

Reversible Canalith Jam of the Horizontal Semicircular Canal Mimicking Cupulolithiasis.

OBJECTIVE: To describe a case of benign paroxysmal positional vertigo (BPPV) resulting in reversible horizontal semicircular canalith jam successfully treated with horizontal canal occlusion. A brief literature review of similar cases was performed. METHODS: Case report and literature review. RESULTS: A 68-year-old female presented with apogeotropic positional nystagmus, attributed to reversible horizontal canalith jam mimicking cupulolithiasis that was refractory to tailored repositioning maneuvers across months. She was unable to work due to the severity of her symptoms. She underwent surgical occlusion of the affected canal with immediate resolution of her symptoms. A literature review revealed similar cases of canalith jam mimicking cupulolithiasis. CONCLUSIONS: Reversible canalith jam, in which particles moving with horizontal head position alternate between obstructing the semicircular canal and resting on the cupula, can mimic signs of cupulolithiasis. This variant of BPPV can be effectively managed with surgical canal occlusion should symptoms fail to resolve after tailored repositioning maneuvers.

Benign Paroxysmal Positional Vertigo and the Increased Risk of Ischemic Stroke: A Nested Case-Control Study Using a National Cohort Sample.

A recent population cohort study reported that benign paroxysmal positional vertigo (BPPV) was a risk factor for ischemic stroke. This study investigated the risk of ischemic and hemorrhagic strokes in patients with BPPV. A nested case-control study used the data from the Korean National Health Insurance Service-National Sample Cohort between 2002 and 2013. We used data of patients aged ≥50 years obtained from the Korean National Health Insurance Service-National Sample Cohort between 2002 and 2013. A total of 15,610 patients with ischemic stroke and 4,923 patients with hemorrhagic stroke were matched for age, sex, income, residential location, hypertension, diabetes, and dyslipidemia with 62,440 and 19,692 controls, respectively. History of BPPV was evaluated in the stroke and control groups. Crude and adjusted odds ratios (ORs) for stroke in patients with BPPV were analyzed using stratified logistic regression analysis. Subgroup analyses were performed for age and sex. Notably, 3.7% (572/15,610) of patients with ischemic stroke and 2.7% (1,702/62,440) of the control subjects reported a history of BPPV (P < 0.001). The adjusted OR for BPPV in patients with ischemic stroke was 1.35 (95% confidence interval (CI) 1.22-1.49, P < 0.001). Patients with ischemic stroke showed higher ORs for BPPV in the subgroup of women. Patients with hemorrhagic stroke did not show a high OR for BPPV. Ischemic stroke patients demonstrated the increased OR for BPPV in subjects aged ≥50 years old.

Characteristics of Benign Paroxysmal Positional Vertigo Following an Earthquake.

INTRODUCTION: Benign Paroxysmal Positional Vertigo (BPPV) is a commonly encountered peripheral vestibular disorder. People exposed to massive earthquakes experience intense and long-term problem associated with dizziness. The purpose of our study is to investigate this relationship and to demonstrate the efficacy of the treatment modalities used in the management of patients with post-earthquake dizziness. METHODOLOGY: The study was carried out by examining the retrospective records of patients who presented with dizziness to the otorhinolaryngological outpatient unit before and after the Elazig earthquake that occurred on 24th Jan 2020. Parameters evaluated include patients' age and gender, onset of dizziness, accompanying symptoms and comorbidities, videonystagmography (VNG) findings, pre- and post-treatment Visual Analogue Scale (VAS), Dizziness Handicap Inventory (DHI), and Hospital Anxiety and Depression Scale (HADS). RESULTS: The number of patients who presented with dizziness to our outpatient clinic after the earthquake and were included in our study totaled 84. The number of patients who visited the outpatient clinic before the earthquake was identified to be 75. In the earthquake related group, while there was a statistically significant difference between residual symptoms (RS) and the need for repetitive repositioning maneuvers, there was no statistically significant difference detected for age, gender, and comorbidities. Also, no statistically significant difference was found in the pre- and post-treatment assessments of VAS, DHI, and HADS median values in the earthquake group. CONCLUSION: There was a remarkable increase in the number of patients presenting with dizziness in the early post-earthquake period. Management of these patients may differ from the classic BPPV. Residual symptoms appearing after performing repositioning maneuvers can be more commonly seen among these patients.

Linear Vertigo in Benign Paroxysmal Positional Vertigo: Prevalence and Mechanism.

This study aimed to determine the prevalence and mechanism of linear vertigo reported by the patients during the attacks of benign paroxysmal positional vertigo (BPPV). We prospectively evaluated the characteristics (rotational vs. linear) of positional vertigo in 70 patients with posterior and horizontal canal BPPV using a questionnaire allowing multiple choices. In patients with linear vertigo, we further assessed the directionality of linear vertigo. We adopted the velocity-storage model to explain the occurrence and direction of linear vertigo in these patients with BPPV. Patients reported only rotational vertigo in 46 (46/70, 65.7%), only linear vertigo in 10 (14.3%), and both rotational and linear vertigo in 14 (20%). The patients experienced fear from rotational vertigo in 54 (54/70, 77.1%) and from linear vertigo in 20 (20/70, 28.6%). The direction of linear vertigo was concordant with the direction of inertial acceleration predicted by the velocity-storage model. Patients with BPPV may experience linear as well as rotational vertigo during the attacks. This linear vertigo may be ascribed to centrally estimated inertial acceleration.

Platform posturography of patients with peripheral vestibular dysfunction in the non-acute phase of vertigo.

OBJECTIVE: Posturography (PG) shows various patterns corresponding to a patient's equilibrium condition; however, PG is not useful for the differential diagnosis of peripheral vestibular diseases (PVDs). The aim of this study was to identify parameters of PG that can distinguish between PVDs. METHODS: The differences in PG parameters between PVDs were evaluated retrospectively. Two hundred and two patients with Ménière's disease (MD), 154 patients with benign paroxysmal positional vertigo (BPPV), 20 patients with sudden sensorineural hearing loss with vertigo (SSNHLwV), and 31 patients with vestibular neuritis (VN) underwent PG during the non-acute phase of vertigo, from January 2010 to March 2017. RESULTS: The velocity of body oscillation of BPPV patients with eyes open and closed were significantly faster than those of MD patients with eyes open (p < 0.001) and closed (p = 0.033). The velocity of body oscillation of VN patients with eyes open was significantly faster than that of MD patients with eyes open (p = 0.0083). There were no significant differences among the other PG parameters between PVDs. Although there were significant differences among the velocity with eyes open and closed between males and females (eye open: p = 0.0009, eye close: p < 0.0001), there was no significant difference in the ratio of males to females among PVDs (p = 0.1834). Therefore, the ratio did not influence the difference in velocity among PVDs. Patient age correlated with the velocity with eyes open (p < 0.001) and with eyes closed (p < 0.001). Post-hoc analysis revealed significant differences in patient age, and comparisons of MD and BPPV, MD and SSNHLwV, BPPV and VN, and VN and SSNHLwV. Therefore, we performed multiple regression analysis to determine whether the significant differences in the velocity of body oscillation among PVDs were caused by the difference in age distribution between PVD groups, rather than by differences in the PVDs themselves. There were correlations between age and the velocity of body oscillation with eyes open (p < 0.001) and with eyes closed (p < 0.001). There also were correlations between MD or VN and the velocity of body oscillation with eyes open (p = 0.0194). CONCLUSION: There were significant differences in the velocity of body oscillation with eyes open between MD and VN patients. The difference between MD and VN was significant regardless of the age distribution. To distinguish between MD and VN, the velocity of body oscillation with eyes open is a useful PG index.

Temperature Measurements of the Semicircular Canal During Green Laser Irradiation of the Canal: A Preliminary Study.

BACKGROUND: Laser irradiation of the semicircular canal (SCC) is a good treatment for intractable benign paroxysmal positional vertigo. However, there were few reports on the temperature changes during laser irradiation. OBJECTIVE: To measure the internal temperature of the SCC and vestibule during green laser irradiation of the SCC and investigate morphologic changes using human temporal bones. METHODS: After the lateral SCC was blue-lined, a thermocouple was inserted into the SCC through a hole made in the canal wall. Another thermocouple was inserted into the vestibule through the oval window. Green laser was irradiated to the lateral canal wall. After the irradiation, the tissues were inspected as paraffin using HE staining. RESULT: The internal temperature of the SCC rose from 33 ° to 52 °C by a single laser irradiation of 1.5 W × 2 seconds and 82 °C by a single laser irradiation of 1.7 W × 3 seconds to the canal wall with a black spot. Continuous laser irradiation of 1.5 W × 3 seconds, 10 times resulted in a temperature rise of 92 °C from 33 °C. Throughout the whole experiments, temperatures within the vestibule were unchanged. Histopathology showed that the irradiated areas of the lateral canal wall were partially deficient with or without carbonization after single irradiation. By continuous laser irradiations, the SCC bony wall showed a peroration of 40 µm in diameter with carbonized edges. CONCLUSIONS: Green laser irradiation of the SCC produced char formation with perforation in the canal wall. High temperatures within the SCC were recorded for a short period of less than 30 seconds. However, the vestibule didn't show temperature changes.

The Impact of the COVID-19 Pandemic on Follow-Ups for Vertigo/Dizziness Outpatients.

OBJECTIVES: In the present report, we aimed to investigate the impact of the coronavirus disease (COVID-19) pandemic on vertigo/dizziness outpatient cancellations in Japan. METHODS: We examined 265 vertigo/dizziness outpatients at the ear, nose, and throat department of the Nara Medical University between March 01, 2020, and May 31, 2020, during the COVID-19 pandemic in Japan. We also focused on 478 vertigo/dizziness outpatients between March 01, 2019, and May 31, 2019, before the COVID-19 pandemic, to compare the number of cancellations between these 2 periods. The reasons for cancellation and noncancellation were investigated using telephone multiple-choice questionnaires (telMCQs), particularly for patients with benign paroxysmal positional vertigo (BPPV) and Meniere's disease (MD). RESULTS: There were many cancellations for medical examinations during the 2020 study period. The total number of vertigo/dizziness outpatients decreased by 44.6% in the 2020 period compared to the same period in 2019. The percent reduction in clinic attendance from 2019 to 2020 (ie, [2019-2020]/2019) for patients with BPPV was higher than that for patients with MD. Compared to the other vertigo-associated conditions, patients with MD exhibited a lower percent reduction in clinic attendance. According to the results of the telMCQs, 75.0% of BPPV cases and 88.2% of MD cases cancelled their appointment and gave up visiting hospitals due to fear of COVID-19 infection, even if they had moderate to severe symptoms. On the contrary, 25.0% and 80.0% patients with BPPV and MD, respectively, did not cancel their appointment; they should not have visited the hospital but stayed at home because they had slight symptoms. CONCLUSIONS: These findings suggest that advanced forms should be prepared for medical care, such as remote medicine. These forms should not only be for the disease itself but also for the mental distress caused by persistent symptoms.

Cervical vestibular evoked myogenic potentials in patients with the first episode of posterior canal benign paroxysmal positional vertigo before and after repositioning.

BACKGROUND: Cervical vestibular evoked myogenic potentials (cVEMPs) are used to assess the sacculo-collic pathways. Benign paroxysmal positional vertigo (BPPV) is mainly a utricular disorder. OBJECTIVES: To investigate cVEMPs in BPPV patients before and after repositioning maneuvers. METHODS: Forty patients with posterior canal BPPV with new onset symptoms underwent cVEMP testing at the time of diagnosis and a month after successful repositioning maneuver. p13, n23 latency and amplitude ratio values were compared with the results of 40 healthy controls. RESULTS: p13 and n23 latencies of the affected side were significantly longer than the healthy controls more prominent for the p13 latency. Comparison of the affected side with the non-affected side revealed delayed p13 latency on the affected side. Though a significant improvement in p13 latency was observed after repositioning, it was still prolonged when compared with the healthy controls. An abnormality regarding amplitudes was not present. CONCLUSIONS AND SIGNIFICANCE: cVEMP abnormalities in patients with BPPV indicate saccular dysfunction accompanying utricular dysfunction which seems to be confined to the symptomatic side at least in the early phase of the disease. Partial recovery can be seen after treatment with residual findings following even the first attack.

Pseudo-spontaneous nystagmus in lateral semicircular canal benign paroxysmal positional vertigo: Correlation with bow and lean test in a pitch plane.

OBJECTIVES: We investigated the incidence and characteristics of pseudo-spontaneous nystagmus (PSN) in benign paroxysmal positional vertigo involving the lateral semicircular canal (LC-BPPV) and evaluated the correlation between PSN and the bow and lean test. METHODS: We examined nystagmus in the sitting position using video-oculography goggles in 131 LC-BPPV patients. The positioning test and bow and lean test were also performed. Patients were divided into canalolithiasis and cupulolithiasis groups according to the character of nystagmus. In each group, the incidence and direction of PSN, correlation with the bow and lean test, and treatment outcome were analyzed. RESULTS: PSN was observed in 25 cases (19.1%) in LC-BPPV patients, 7 of which were canalolithiasis and 18 of which were cupulolithiasis (p = 0.098). Of the 25 patients with PSN, 21 (84%) exhibited nystagmus consistent with the lean test whereas 4 (16%) exhibited nystagmus consistent with the bow test. In patients with PSN, nystagmus was observed in the bow and lean test in all cases (23/23), but in patients without PSN, no nystagmus was observed in 13 cases (13/87) in the bow and lean test (p = 0.048). The number of barbecue maneuvers performed until the end of treatment was 1.4 ± 0.7 in patients with PSN and 1.4 ± 0.9 in those without PSN (p = 0.976). CONCLUSION: We identified PSN in patients with LC-BPPV irrelevant of subtype. Moreover, all patients with PSN showed nystagmus in the bow and lean test. The direction of PSN was mostly consistent with that of the lean test (21/25, 84%). The presence of PSN was not related to the treatment outcome in this study.

Balance performance when responding to visual stimuli in patients with Benign Paroxysmal Positional Vertigo (BPPV).

BACKGROUND: Patients with Benign Paroxysmal Positional Vertigo (BPPV) often report a sensation of disequilibrium before treatment with the canalith repositioning maneuvers. Apart from vestibular information, visual input also contributes to balance control. How visual stimuli influence balance control in BPPV patients is unclear. OBJECTIVE: To investigate the influence of visual stimuli on balance performance in BPPV patients. METHODS: Three groups of participants, patients with BPPV, and healthy young and older adults, were instructed to stand under three conditions: 1) eyes open (EO); 2) while watching a static picture via a video display; and 3) while watching a rotating visual scene. Antero-posterior (AP), lateral (ML), and total sway path during standing were analyzed. RESULTS: In all conditions, patients with BPPV showed significantly larger AP, ML and total sway path than young, whereas older adults only showed significantly larger AP and total sway path than young adults. During the visual stimuli, all participants exhibited significantly increased AP and total sway while watching a static image and a moving scene as compared with the EO condition. CONCLUSIONS: Patients with BPPV have similar balance control to older adults, but poorer balance control than young adults. The reduced lack of standing balance control in the coronal plane of patients with BPPV, might affect balance strategy after external perturbations.

Canalith repositioning procedure improves gait and static balance in people with posterior semicircular canal benign paroxysmal positional vertigo.

BACKGROUND: Investigations measuring gait tests have rarely been studied in the benign paroxysmal positional vertigo (BPPV) population. OBJECTIVE: Examine instrumented mobility metrics in people with posterior semicircular canal BPPV. We examined the impact of a canalith repositioning procedure (CRP), prior to and after treatment on instrumented mobility measures, comparing the scores to those of healthy controls. METHODS: At baseline, the subject performed a series of instrumented gait and balance tests and then, the CRP was performed. At re-evaluation (1-week later), identical gait and balance tests were assessed. In addition, the Hallpike-Dix test identified patients who had improved or had not improved in their BPPV signs and symptoms. RESULTS: Thirty-two people with BPPV (25 women) and 15 healthy subjects participated in the study. At baseline (pre-CRP), people with BPPV demonstrated an increased vestibular ratio, and walked more slowly compared with the healthy controls. The CRP resolved the vertigo in 90.6% of the BPPV subjects. Compared with the pre-CRP scores, the BPPV subjects demonstrated a decreased vestibular ratio and faster walking at the post-CRP evaluation. Out of the five parameters that were significantly different from the healthy values pre-CRP, only one remained different post-CRP. CONCLUSIONS: Besides vertigo and balance difficulties, people with BPPV demonstrate walking modifications. Furthermore, the CRP has a high success rate in improving not only vertigo but also in restoring gait and balance in persons with BPPV.

Optimizing Testing for BPPV - The Loaded Dix-Hallpike.

OBJECTIVES: Although the Dix-Hallpike testing is generally considered as the gold standard for the identification of the posterior canal benign paroxysmal positional vertigo (BPPV), we investigated a modification of the maneuver termed the "loaded Dix-Hallpike." STUDY DESIGN: Prospective randomized controlled trial. MATERIALS AND METHODS: Twenty-eight patients participated in this prospective study comparing the standard Dix-Hallpike (S-DH) to the loaded Dix-Hallpike (L-DH) test. Each patient underwent repeated testing with the S-DH and the L-DH. The patients were placed into two groups. Fourteen patients underwent 3 rounds of S-DH testing followed by 3 rounds of L-DH testing. The other fourteen patients underwent 3 rounds of L-DH testing followed by 3 rounds of S-DH testing. The duration of nystagmus and the latency prior to the onset of nystagmus were measured for each test. Additionally, the patients were asked to rate the severity of their symptoms following each test. RESULTS: The duration of nystagmus of the L-DH was significantly longer than that of the S-DH (p<0.0001). The patients reported a higher severity score with L-DH as compared to with S-DH (p<0.001). The L-DH was found to be more sensitive than the S-DH (p=0.0131). CONCLUSION: The L-DH produces significantly longer duration of nystagmus, stronger symptoms, and improved sensitivity when compared to the S-DH.

Treatment of Benign Paroxysmal Positional Vertigo with the TRV Reposition Chair.

OBJECTIVES: The primary objective of this study was to evaluate how successful the reposition of retractable benign paroxysmal positional vertigo (BPPV) was when treating patients with the Thomas Richard Vitton (TRV) reposition chair. MATERIALS AND METHODS: This is a prospective clinical trial. A total of 81 BPPV patients who were referred to the tertiary Balance - Dizziness Centre at the Department of Otolaryngology, Head - Neck Surgery and Audiology, Aalborg University Hospital, Denmark were included and analyzed. All the patients were diagnosed and treated with the TRV reposition chair. RESULTS: The patients were successfully treated after an average of 2.23 (± 1.66 SD) treatments with the TRV reposition chair. There was a significant difference between the number of treatments needed in the single semicircular canal group and the multicanal group. Seventeen (22.6%) of the patients experienced either dislocation of otoconia, relapse, or new onset of BPPV during the trial period. The number of patients with BPPV located to the anterior, lateral, and multiple semicircular canals in this study was significantly higher than that in similar studies. Six patients (7.4%) were classified as treatment failures. CONCLUSION: We found the TRV reposition chair to be very successful in the diagnostics and treatment of patients with retractable and atypical BPPV. However, 7.4% experienced treatment failure.

Video head impulse testing in patients with benign paroxysmal positional vertigo.

BACKGROUND: Vestibulo-ocular reflex (VOR) function is expected to be normal in patients with benign paroxysmal positional vertigo (BPPV) during sudden head rotations. AIM: The aim of this study is to analyze VOR by video head impulse test (vHIT) in patients with BPPV in order to determine the potential value of clinical application of vHIT in BPPV. MATERIAL AND METHOD: Sixty patients with BPPV were included for the study from out-patient admissions. The main outcome measures were the gain of VOR, gain asymmetry, and refixation saccades. Fifteen healthy subjects with no history of dizziness were selected as normal control. RESULTS: Mean VOR gain during lateral head impulse in patients with geotropic type LC BPPV was 0.85 ± 0.22. Mean VOR gain during lateral head impulse in patients with ageotropic type LC BPPV was 0.78 ± 0.16. Fourteen patients with PC BPPV (35%; 40/13) had low gain during ipsilesional head impulses. Seven patients had low gain during counterlesional head impulses. Mean VOR gain during vertical head impulse in patients with PC BPPV was 0.73 ± 0.24. Nine patients with posterior canal BPPV (25%; 9/40) and 2 patients with LC BPPV (11%; 2/18) had corrective saccades. None of the results showed significant difference in comparison to control group. CONCLUSION AND SIGNIFICANCE: VHIT analysis demonstrated that VOR function was normal on the BPPV side.

Light Cupula: To Be Or Not to Be?

Benign paroxysmal positional vertigo (BPPV) represents the most common form of positional vertigo. It is caused by dislodged otoconia that freely float in the semicircular canals (canalolithiasis) or attach to the cupula (cupulolithiasis). A cupulolithiasis-type (or a heavy cupula-type) of BPPV implicating the lateral semicircular canal (LSCC) exhibits persistent ageotropic direction-changing positional nystagmus (DCPN) in a head-roll test. However, in some cases, unlike any type of BPPV, persistent geotropic DCPN cannot be explained by any mechanisms of BPPV, and don't fit the current classifications. Recently, the notion of light cupula has been introduced to refer to the persistent geotropic DCPN. In this study, we looked at the clinical features of light cuplula and discussed the possible mechanisms and therapeutic strategies of the condition. The notion of light cupula is a helpful addition to the theory of peripheral positional vertigo and nystagmus.

A new variant of posterior canal-benign paroxysmal positional vertigo-canalolithiasis.

OBJECTIVE: The characteristics of typical posterior canal-benign paroxysmal positional vertigo-canalolithiasis (P-BPPV-Can) are well known. We found 10 patients with a new variant of P-BPPV-Can: Reverse (Rev)-P-BPPV-Can. The characteristics and pathophysiology of Rev-P-BPPV-Can are discussed. METHODS: For 4 years and 9 months, 10 patients with Rev-P-BPPV-Can (9 women and 1 man; mean age: 73 years) visited our clinic. Within the same period, 268 patients with unilateral typical P-BPPV-Can were treated. During the Dix-Hallpike and Epley maneuvers, nystagmus was recorded using an infrared charge-coupled device camera mounted on a pair of spectacles. RESULTS: The patients exhibited entirely opposite direction of nystagmus from typical P-BPPV-Can in both the Dix-Hallpike head position and upright sitting position. The patients had typical characteristics of nystagmus due to canalolithiasis, such as latency, duration of <1 min, linear-torsional nystagmus, and fatigability. Rev-P-BPPV-Can appeared after the Epley maneuver for typical P-BPPV-Can; in other patients, Rev-P-BPPV-Can changed to typical P-BPPV-Can. The affected sides of Rev-P-BPPV-Can were decided by those of typical P-BPPV-Can. CONCLUSION: Canalolithiasis in the non-ampullary distal portion of the posterior semicircular canal may be a potential pathophysiology of Rev-P-BPPV-Can. The Epley maneuver has little effect for treating Rev-P-BPPV-Can, but spontaneous transition to typical P-BPPV-Can or spontaneous recovery is expected.

Upright positioning-related reverse nystagmus in posterior canal benign paroxysmal positional vertigo and its effect on prognosis.

BACKGROUND: Positional nystagmus elicited by the Dix-Hallpike maneuver often reverses its direction as the patient is re-seated from the provoking head hanging position. The incidence of reverse nystagmus and its association with prognosis in posterior canal benign paroxysmal positional vertigo (pcBPPV) is not clear. OBJECTIVE: To determine the incidence of upright positioning-related reverse nystagmus and its association with the success of canalith repositioning (Epley) maneuver (CRM) treatment in pcBPPV. METHODS: The records of patients that had been tested with video-nystagmography in a tertiary care center, between October 2016 and March 2019, were reviewed. Data were obtained from detailed analysis of video recordings of 321 patients with typical pcBPPV. RESULTS: Reverse nystagmus was determined in 85% of the patients with pcBPPV. The number of CRMs required for treatment was lower in patients with reverse nystagmus (1.32±0.68) compared to patients without reverse nystagmus (1.81±0.98) (p < 0.001). There was not a statistically significant relationship between reverse nystagmus and recurrence (p = 0.623). CONCLUSIONS: The absence of reverse nystagmus on upright positioning during the Dix-Hallpike test predicts poor success for the CRM, as repetitive repositioning maneuvers might be required to achieve successful treatment in pcBPPV.

Burden of vertigo at home: Risks for patients with vertigo.

OBJECTIVE: We aimed to clarify the burden of vertigo in patients' homes. METHODS: This was a questionnaire survey among patients with vestibular vertigo. Four main questions were prepared. Q1: Where did you first notice vertigo? Q2: Where have you had the most difficulty with vertigo in your home? Q3: Where do you have difficulty at present? Q4: What household equipment have you used as a countermeasure to prevent further problems with vertigo? RESULTS: Sixty patients completed the questionnaire. Benign paroxysmal positional vertigo (BPPV) was most common among respondents, followed by Ménière's disease. Q1: Most patients with BPPV first noticed vertigo in the bedroom; patients with other diseases first noticed vertigo in the living room. Q2: Both groups previously had the most difficulty with vertigo in the same locations as in Q1; these differences were significant between Q1 and Q2. Q3: Both groups had the most difficulty on stairs. Q4: Handrails were the most often used equipment for vertigo in both groups. There was no significant difference between Q3 and Q4. CONCLUSION: Our data revealed that the locations of risks differ among patients with vestibular disorders. Handrails were considered the most important equipment to prevent problems with vertigo.