Atypical Benign Paroxysmal Positional Vertigo Research Articles

Seven years of experience with treatment of benign paroxysmal positional vertigo with a mechanical rotational chair.

BackgroundThroughout the last decade, several mechanical rotational chairs have been developed for diagnostics and treatment of patients with a typical case history of benign paroxysmal positional vertigo. Sparse evidence, however, exists in terms of diagnostic accuracy and treatment efficiency with these mechanical rotational chairs. Also, recommendations for optimal use of these chairs are yet to be determined.ObjectivePrimary objective was to evaluate overall treatment of benign paroxysmal positional vertigo with a mechanical rotational chair and secondary objectives included description of patient- and BPPV characteristics, determination of subjective and objective outcomes, as well as analyzation of recurrence- and recurrence-related risk factors following successful treatment.MethodsRetrospective cohort study with 635 patients diagnosed with benign paroxysmal positional vertigo and treated by means of a mechanical rotational chair during a 7-year period from 2014 to 2021 at a tertiary University hospital. Patient- and disease-specific characteristics, treatment and recurrence data were collected through reviewing of patient records.ResultsThe mean number of required treatments was 2.7 when accounting for a six percent treatment failure rate (defined as a need of more than 10 treatments), and 3.7 when not. Bilateral mono-canal affection required 3.8 treatments, unilateral multi-canal 3.5 treatments, and the combination of bilateral and multi-canal affection 5.2 treatments. All these scenarios were associated with significantly higher numbers of required treatments when compared to unilateral mono-canal affection, which required 1.9 treatments. The overall recurrence rate was 25.4 percent.ConclusionA mechanical rotational chair provides successful treatment of benign paroxysmal positional vertigo. Mechanical rotational chairs should primarily be reserved for the treatment of retractable and atypical benign paroxysmal positional vertigo patients. Many aspects of the optimal use of these chairs still require elaborative assessment.

Patients' Experiences with Management of Benign Paroxysmal Positional Vertigo: Insights from the Vestibular Disorders Association Registry.

IntroductionBenign paroxysmal positional vertigo (BPPV) is the most frequently occurring peripheral vestibular disorder. Clinical practice guidelines (CPG) for BPPV exist; however, little is known about how affected patients perceive their condition is being managed. We aimed to leverage registry data to evaluate how adults who report BPPV are managed.Material and MethodsWe retrospectively analyzed of data from 1,262 adults (58.4 ± 12.6 years old, 81.1% female, 91.1% White) who were enrolled in the Vestibular Disorders Association Registry from 2014 to 2020. The following patient-reported outcomes were analyzed by proportions for those who did and did not report BPPV: symptoms experienced, falls reported, diagnostics undertaken, interventions received (eg, canalith repositioning maneuvers [CRMs], medications), and responses to interventions.ResultsOf the 1,262 adults included, 26% reported being diagnosed with BPPV. Many adults who reported BPPV (83%) also endorsed receiving additional vestibular diagnoses or may have had atypical BPPV. Those with BPPV underwent magnetic resonance imaging and were prescribed medications more frequently than those without BPPV (76% vs 57% [χ2=36.51, p<0.001] and 85% vs 78% [χ2=5.60, p=0.018], respectively). Falls were experienced by similar proportions of adults with and without BPPV (55% vs 56% [χ2==11.26, p=0.59]). Adults with BPPV received CRMs more often than those without BPPV (86% vs 48%, χ2=127.23, p<0.001). More registrants with BPPV also endorsed benefit from CRMs compared to those without BPPV (51% vs 12% [χ2=105.30, p<0.001]).DiscussionIn this registry, BPPV was often reported with other vestibular disorders. Healthcare utilization was higher than would be expected with care based on the CPG. The rates of falls in those with and without BPPV are higher than previously reported. Adults with BPPV reported significant differences in how their care is managed and their overall outcomes compared to those without BPPV.ConclusionPatient-reported outcomes provide useful information regarding the lived experience of adults with BPPV.

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

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. 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. 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. 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.

Head-Up Sleep May Cure Patients With Intractable Benign Paroxysmal Positional Vertigo: A six-Month Randomized Trial.

ObjectivesThe aim of the present study was to assess head‐position management for intractable idiopathic benign paroxysmal positional vertigo (BPPV) when lying down. We hypothesized that head‐up sleep (HUS) could prevent free‐floating otoliths from entering the semicircular canals.Study DesignA prospective two‐arm multicenter randomized controlled trial.MethodsBPPV was diagnosed in 611 patients (611/1,520; 40.2%) according to the 2015 diagnostic guidelines issued by the International Classification of Vestibular Disorders. Among them, 201 patients were intractable (201/611; 32.9%), 88 of whom were idiopathic and subsequently enrolled in the study. Patients randomly received intervention with HUS at greater than 45° (n = 44) or head‐down sleep (HDS; n = 44) when lying down. Before treatment, they completed several examinations, including subjective visual vertical (SVV). The specific diagnoses for the 88 patients with BPPV included horizontal type cupula (n = 40), horizontal type canal (n = 13), posterior type (n = 26), and probable and/or atypical BPPV (n = 9).ResultsPatient backgrounds did not differ significantly between the HUS and HDS groups. Visual analog scale (VAS) scores of vertiginous sensation were significantly lower in the HUS group than in the HDS group at both the third month and sixth month post‐treatment. Positional/positioning nystagmus observed just before treatment disappeared significantly more often in the HUS group than in the HDS group until the sixth post‐treatment month. Further, especially in HUS group, VAS scores in SVV− group (n = 24) were significantly lower than those in the SVV+ group (n = 20) sixth month post‐treatment.ConclusionsControlling free‐floating otoliths is not easy due to aging of the otolith organs. Repeatedly returning the endless free‐floating debris from the canals to the utricle through physical means is not a good strategy. Therefore, HUS when lying down at home could be recommended as an initial treatment for patients with intractable idiopathic BPPV.Level of Evidence1b

Idiopathic benign paroxysmal positional vertigo with persistent vertigo/dizziness sensation is associated with latent canal paresis, endolymphatic hydrops, and osteoporosis

ObjectiveThe aim of the present study was to examine the association of neuro-otological examination, blood test, and scoring questionnaire data with treatment-resistant intractability in idiopathic benign paroxysmal positional vertigo (BPPV) patients. MethodsWe experienced 1520 successive vertigo/dizziness patients at the Vertigo/Dizziness Center in Nara Medical University during May 2014 to April 2018. Six hundred and eleven patients were diagnosed as BPPV (611/1520; 40.2%) according to the diagnostic guideline of the International Classification of Vestibular Disorder in 2015. Among BPPV patients, there were 201 intractable patients (201/611; 32.9%), 66 of whom were idiopathic and enrolled to be hospitalized and receive neuro-otological examinations, including the caloric test (C-test), vestibular evoked cervical myogenic potentials (cVEMP), subjective visual vertical (SVV), glycerol test (G-test), electrocochleogram (ECoG), inner ear magnetic resonance imaging (ieMRI), blood tests including anti-diuretic hormone (ADH) and bone alkaline phosphatase (BAP), and self-rating questionnaires of depression score (SDS). Sixty-six patients were diagnosed as horizontal type cupula (hBPPVcu; n=30), horizontal type canal (hBPPVca; n=10), posterior type (n=20), and probable and/or atypical BPPV (n=6). Data are presented as ratios (+) of the number of idiopathic BPPV patients with examination and questionnaire data outside of the normal range. ResultsThe ratio (+) data were as follows: C-test=21.2% (14/66), cVEMP=24.2% (16/66), SVV=48.5% (32/66), G-test=18.2% (12/66), ECoG=18.2% (12/66), ieMRI=12.1% (8/66), ADH=9.1% (6/66), BAP=13.6% (9/66), and SDS=37.9% (25/66). Multivariate regression analysis revealed that the periods of persistent vertigo/dizziness were significantly longer in BPPV patients with hBPPVcu, C-test (+), endolymphatic hydrops (+), and BAP (+) compared with those with negative findings. ConclusionAlthough patients with idiopathic BPPV are usually treatable and curable within 1 month, the presence of hBPPVcu, canal paresis, endolymphatic hydrops, and elevated BAP may make the disease intractable, and thus require additional treatments.

Chiari type 1 malformation presenting as an atypical benign paroxysmal positional vertigo in a 16 year old patient

&lt;p&gt;Dizziness and vertigo are very common symptoms and can be difficult to distinguish clinically. Vertigo is a specific subtype of dizziness in which a patient experiences the illusion of motion (often rotatory) of either themselves or their surroundings. Vertigo can be either peripheral (arising within the labyrinth) or central (brain). It is important to identify central aetiologies as they can be fatal if missed. This case report narrates a 16-year-old male who presented complaining of vertigo related to changes in head position which was initially misdiagnosed as a benign paroxysmal positional vertigo (BPPV). It was several years before he was correctly diagnosed as having Chiari type 1 malformation on MRI scan. He underwent a surgical decompression with complete alleviation of his symptoms. All cases of atypical vertigo should be evaluated in detail. Patients with failure of initial management should undergo imaging to identify any central pathology. &lt;/p&gt;

Acute Treatment of an Atypical Benign Paroxysmal Positional Vertigo Variant Postsevere Traumatic Brain Injury

Background and Purpose: The differential diagnosis and treatment of peripheral vestibular disorders in persons with traumatic brain injury presents a complex set of challenges. In the acute rehabilitation setting, orthopedic and medical restrictions, agitation, and/or the inability of the patient to verbalize current symptoms present barriers to many traditional means of assessment and intervention. The purpose of this article is to present a case report of 2 patients successfully treated in the acute inpatient rehabilitation setting postsevere traumatic brain injury with an atypical variant of horizontal canal benign paroxysmal positional vertigo in which both examination and intervention modifications were required in a novel context when applied to this patient population. Case Description: Two patients were consulted to have a vestibular rehabilitation examination performed given interdisciplinary reports of nystagmus and in 1 case significant emesis associated with bed mobility. Both patients presented as Rancho Los Amigos classification 3 to 4, were nonverbal, and presented with multiple comorbidities. Intervention: Both patients were treated for apogeotropic horizontal canal benign paroxysmal positional vertigo using a sequence of bedside canalith repositioning maneuvers safely and efficiently accommodating the clinical brain injury presentation. Outcomes: Both patients demonstrated complete remission of horizontal nystagmus and remission of associated emesis in the 1 case allowing for increased interdisciplinary rehabilitation participation. Discussion: This case report illustrates how application of recent scientific and clinical evidence may be applied within the early acute brain injury population. Vestibular rehabilitation may be an important component to acute neurological rehabilitation posttraumatic brain injury, even when the patient cannot actively verbalize symptoms. In these cases, the clinician must then use a collaborative approach as well as a clinical decision-making model on the basis of an understanding of the neurological underpinning of eye movements and nystagmus.

Typical and atypical benign paroxysmal positional vertigo: literature review and new theoretical considerations.

Atypical variants of benign paroxysmal positional vertigo (BPPV) are often encountered and frequently confusing. The authors present a hypothetical framework that accounts for all classical patterns of BPPV and several unusual variants such as BPPV without nystagmus, BPPV with downbeat nystagmus and BPPV with paradoxically direction-changing nystagmus. The authors introduce new concepts, such as "ipsicanal switch" and "horizontal short arm canalolithiasis" and suggest that their use may improve diagnosis and treatment in everyday clinical practice. The possible consequences of saccular otoconia detachment are reviewed according to the literature.

Transmastoid semicircular canal occlusion: A safe and highly effective treatment for benign paroxysmal positional vertigo and superior canal dehiscence

Transmastoid occlusion of the superior semicircular canal in superior semicircular canal dehiscence (SSCD) syndrome and the posterior semicircular canal in intractable benign paroxysmal positional vertigo (BPPV) will produce resolution of preoperative symptoms. Retrospective review, quality assurance. Sixteen patients with SSCD and 61 patients (65 ears) with intractable BPPV who underwent canal occlusion were reviewed. All patients underwent occlusion of the affected semicircular canal through a transmastoid approach. Preoperative symptoms (vestibular, 13 patients; pulsatile tinnitus, 2 patients; or hyperacusis, 1 patient) were greatly improved or completely resolved in 15 of the 16 SSCD patients who underwent transmastoid occlusion of the superior canal. Hearing was preserved in 14 patients and improved in two patients. Vestibular symptoms were resolved in all intractable BPPV patients who underwent transmastoid occlusion of the posterior canal. One patient had a late recurrence of atypical BPPV. Almost all BPPV patients with normal preoperative hearing have an initial transient postoperative hearing loss, which when tested for is usually a mild to moderate mixed loss. Delayed sensorineural hearing loss was noted in three patients; one loss was profound whereas two were mild. The transmastoid approach to canal plugging is successful in the treatment of symptoms in both SSCD and intractable BPPV, and is a familiar approach for the otologist. This is a viable alternative to the middle fossa approach for SSCD, thereby avoiding a craniotomy. Transmastoid is the definitive approach for posterior canal occlusion.