Persistent Direction-changing Positional Nystagmus Research Articles

Analysis of persistent geotropic and apogeotropic positional nystagmus of the lateral canal benign paroxysmal positional vertigo

ObjectiveThis study aims to analyze the clinical characteristics of persistent geotropic and apogeotropic positional nystagmus of LC-BPPV in view of light and heavy cupula discussion. Material and methodThe study group includes 184 patients with LC BPPV (98 apogeotropic, 86 geotropic type) who have been examined between 2009 and 2020. Ninety-nine females and 85 males, aged between 16 and 92 years were included (Ageotropic 49.32 ± 14.12, geotropic 44.49 ± 13.90 years). Average slow phase velocity (SPV) of positional nystagmus was documented and those with persistent direction-changing positional nystagmus lasting more than a minute were grouped separately. Age, gender difference, side of involvement, and recurrence pattern were particularly reviewed. Chi-square and One way ANOVA tests were used to compare the difference between groups. Statistical significance was set at P < 0.05. ResultsThirty-seven patients with apogeotropic nystagmus (30.7%; 37/98) and 18 patients with geotropic nystagmus (20.9%; 18/86) had persistent nystagmus (p ˂0.05). Comparison of slow phase velocity (SPV) of persistent and non-persistent geotropic and apogeotropic positional nystagmus of the affected side was significant (p ˂0.05). Comparison of average age, male to female ratio, side of involvement, and the recurrence rate in patients with persistent and non-persistent geotropic and apogeotropic type positional nystagmus groups were not significant (p = 0.177, p = 0.521, p = 0.891, p = 0.702). ConclusionPersistent geotropic and apogeotropic positional nystagmus is mostly correlated with the size, amount, and position of otoconial debris. It is difficult to justify the light cupula as a new geotropic variant of cupular pathology. Patients with persistent positional nystagmus present similar therapeutic outcomes and recurrence rates.

Clinical Manifestations of Benign Paroxysmal Positional Vertigo of the Horizontal Semicircular Canal: Pathophysiology of Atypical Manifestations

The presence of a direction changing positional nystagmus (DCPN) in a patient with vertigo is the characteristic sign to diagnose a benign paroxysmal positional vertigo of the horizontal semicircular canal (HSC-BPPV). If a persistent DCPN is observed when positional tests are performed, a light or heavy cupula phenomenon must be suspected. In order to differentiate between these clinical phenomena, a null plane test should be considered for diagnosis. On the other hand, when a paralytic or irritative fixed direction nystagmus is found, then a complete or incomplete jamming within the HSC may be involved. In this particular situation a head shaking nystagmus test may be clarifying. When persitent DCPN or paralytic-irritative nystagmus are found in positional testing, ENT clinicians must keep alert to search for atypical clinical forms of HSC-BPPV.

A Case of Persistent Direction-Changing Positional Nystagmus with Sudden Sensorineural Hearing Loss

A Case of Persistent Direction-Changing Positional Nystagmus with Sudden Sensorineural Hearing Loss

Differences in the Head Roll Test, Bow and Lean Test, and Null Plane between Persistent and Transient Geotropic Direction-Changing Positional Nystagmus.

Background: Persistent geotropic direction-changing positional nystagmus (DCPN) has the characteristics of cupulopathy, but its underlying pathogenesis is not known. We investigated the relationship of the results of the head roll test, bow and lean test, and side of the null plane between persistent and transient geotropic DCPN to determine the lesion side of persistent geotropic DCPN and understand its mechanism. Methods: We enrolled 25 patients with persistent geotropic DCPN and 41 with transient geotropic DCPN. We compared the results of the head roll test, bow and lean test, and side of the null plane between the two groups. Results: The rates of bowing and leaning nystagmus were significantly higher in the persistent DCPN group. Only 16.0% of the persistent DCPN patients had stronger nystagmus in the head roll test and the null plane on the same side. The rates of the direction of bowing nystagmus in the bow and lean test and stronger nystagmus in the head roll test on the same side were also significantly lower in persistent DCPN than in transient DCPN. Conclusion: It was difficult to determine the lesion side in persistent geotropic DCPN using the direction of stronger nystagmus in the head roll test and null plane when the direction of the stronger nystagmus and null plane were opposite. Further study is needed to understand the position of the cupula according to head rotation and the anatomical position in persistent geotropic DCPN.

Clinical Findings in Patients With Persistent Positional Nystagmus: The Designation of "Heavy and Light Cupula".

Objective: Direction-changing positional nystagmus (DCPN) had been observed as persistent horizontal apogeotropic and was considered as “cupulolithiasis or heavy cupula. ” Recently, the concept of “light cupula” exhibiting persistent geotropic DCPN has been introduced. However, the light cupula is not systematically described, while the identification and diagnosis of “light cupula” should be improved. Here we investigated the underlying characteristics and therapeutic options designed to the “light” and “heavy” cupula, respectively; and summarized the clinical characteristics and therapeutic effect in the two groups.Methods: A total of 359 cases with vertigo and bilateral DCPN were found in the supine roll test. Only 25 patients with persistent DCPN were enrolled and followed up. According to the direction of nystagmus, we further divided the patients into “heavy cupula” (apogeotropic) and “light cupula” (geotropic) groups. We compared the incidence, characteristics of nystagmus and the efficacy of repositioning maneuver in the two groups.Results: Nine patients with persistent horizontal geotropic DCPN were confirmed as “light cupula,” other 16 patients with persistent horizontal ageotropic DCPN were confirmed as heavy cupula. All 25 patients had null plane; the mean value and standard deviation of the null plane in light cupula and heavy cupula was 25.67 ± 9.31° and 27.06 ± 6.29°, respectively. The mean value and standard deviation of the termination plane in light cupula was 28.78 ± 10.00°, and 30.25 ± 6.53° in heavy cupula. There was no statistical significance between the two groups. We found that the direction of evoked nystagmus in the supine position was toward the intact side in light cupula, while in heavy cupula, it was toward the lesion side. The null plane appeared on the lesion side. For light cupula patients, the effect was not obvious at Day-7 after the treatment, however, treatment for most heavy cupula patients were effective. All patients recovered after 30 days of treatment.Conclusion: The null plane is crucial in determining the lesion side for light or heavy cupula. Although the short-term therapeutic effect of the light cupula is not as promising as the effect seen in heavy cupula, the long-term prognosis in both groups is comparable; with all patients recovered after 30 days of treatment.Study design: This is a retrospective cohort study.

The “light cupula” phenomenon masquerading in congenital nystagmus

Abstract Objective/Hypothesis: Congenital nystagmus alone does not cause vertigo or dizziness, but we often encounter patients with this condition who complain of dizziness or vertigo. These patients also show positional nystagmus under an infrared camera (opened in the dark). Among them, we found a patient who had persistent direction changing positional nystagmus (DCPN) with two neutral points. This type of nystagmus is thought to be due to “light or heavy cupula” of the affected ear’s lateral semi-circular canal (SCC). The neutral point is deviated to the right or left from the supine position (first neutral point), and the deviated side is the affected side. If “light or heavy cupula” reflects the pathological condition of the endolymph in the affected ear lateral SCC, the side of the neutral point is thought to show the side of vestibular disorder. Case Report: The patient was a 51-year-old woman who complained of sudden onset of vertigo and hearing loss in the left ear. After admission therapy, hearing loss improved, but nystagmus did not disappear. She was diagnosed as having congenital nystagmus by typical electronystagmography. After this, she suffered vertiginous episodes and her left hearing level fluctuated and deteriorated. She was diagnosed with Meniere's disease. Simultaneously, she also showed persistent DCPN with two neutral points (“light cupula” type was observed eight times and “heavy cupula” type was twice.), whose first neutral point’s side changed at each time. Finally, she continued showing “light cupula” type persistent DCPN with two neutral points. Conclusion: The clinical characteristics of our patient suggested that bilateral latent vestibular disorder can occur in patients with Meniere's disease suffering from unilateral hearing impairment behind the congenital nystagmus. Persistent DCPN including “light cupula” can be explained by changes of the specific gravity of the surrounding endolymph in the affected ear.

Persistent Positional Vertigo in a Patient with Sudden Sensorineural Hearing Loss: A Case Report.

Because inner ear organs are interconnected through the endolymph and surrounding endolymphatic membrane, the patients with sudden sensorineural hearing loss (SSNHL) often complain of vertigo. In this study, we report a patient with SSNHL accompanied by persistent positional vertigo, and serial findings of head-roll tests are described. At acute stage, head-roll test showed persistent geotropic direction-changing positional nystagmus (DCPN), which led to a diagnosis of SSNHL and ipsilateral light cupula. Although vertigo symptom gradually improved, positional vertigo lasted for more than 3 weeks. At this chronic stage, persistent apogeotropic DCPN was observed in a head roll test, which led to a diagnosis of the heavy cupula. Although the mechanism for the conversion of nystagmus direction from geotropic to apogeotropic persistent DCPN is unclear, the change of specific gravity of the endolymph might be one of the plausible hypothetical explanations.