Unilateral Benign Paroxysmal Positional Vertigo Research Articles

Galvanic vestibular stimulation versus transcutaneous electrical nerve stimulation in patients with unilateral benign paroxysmal positional vertigo

Abstract OBJECTIVE: The purpose of this study was to compare the efficacy of galvanic vestibular stimulation (GVS) with transcutaneous electrical nerve stimulation (TENS) in patients with benign paroxysmal positional vertigo (BPPV) due to unilateral vestibular dysfunction. MATERIALS AND METHODS: Twenty patients both males and females with unilateral BPPV and mini-mental status examination ≥24 were randomized equally in either of the two groups (group A and group B). Galvanic stimulus was delivered to group A patients transcutaneously, whereas TENS was administered to group B patients. The study included the pre and posttest measurement of the dependent variables on the scores obtained on vestibular ocular motor screening and Vertigo Symptom Scale (VSS). RESULTS: The GVS group improved in their levels of dizziness, with pretest score of 2.53 ± 1.599 and posttest score of 0.33 ± 0.705; P = 0.00 and the levels of headache with pretest score of 2.30 ± 2.25 and posttest score of 0.92 ± 1.279; P = 0.015, which is statistically significant compared to those in peripheral nerve stimulation group with TENS on neck muscles. The GVS group improved on two items on the VSS scale pain in the heart or chest region with a pretest score value of 1.89 ± 0.315 and posttest score value of 0.00 ± 0.000; feeling of ear pressure with a pretest score of 1.75 ± 0.215 and posttest score value of 0.00 ± 0.000; P = 0 compared with those in peripheral stimulation group. RESULTS: GVS was more effective in reducing the symptoms associated with unilateral BPPV than TENS.

Evaluation of Mental Rotation Ability in Patients with Unilateral Benign Paroxysmal Positional Vertigo.

Our study aims to determine whether there are differences in mental rotation abilities between unilateral benign paroxysmal positional vertigo patients and healthy controls using object-based mental rotation tasks. Our study included 17 unilateral posterior canal benign paroxysmal positional vertigo patients and 20 healthy adults. Spontaneous nystagmus test, saccade test, and dynamic positional tests with videonystagmography and object-based mental rotation test with 2-dimensional images of cubes rotated at certain angles in 3-dimensional space were performed on the participants. The mental rotation test response time and the number of correct answers were compared between patients and controls. We also evaluated whether there was a relationship between saccade test parameters and mental rotation test parameters in our study. No significant relationship was found between benign paroxysmal positional vertigo patients and controls on any of the dependent measures (P -gt; .05). When we evaluated the relationship between saccadic latency and accuracy and mental rotation test response time and number of correct answers in benign paroxysmal positional vertigo patients, no significant relationship was found (P -gt; .05). Our findings show that unilateral, posterior canal benign paroxysmal positional vertigo does not affect object-based mental rotation performance. In our study, no correlation was found between saccadic function and mental rotation ability in unilateral benign paroxysmal positional vertigo patients.

The role of electrocochleography and the caloric test in predicting short-term recurrence of benign paroxysmal positional vertigo.

The study aimed to assess the value of physiological tests for evaluating inner ear function in predicting the short-term recurrence of benign paroxysmal positional vertigo (BPPV). The clinical information of all idiopathic BPPV patients who were treated in our clinic between February 2021 and December 2022 were reviewed. All patients included in the study had completed audiology examinations including pure tone audiometry, electrocochleography (EcochG), auditory brainstem response, and vestibular function examination such as the vestibular caloric test. The relationships between the results of the above tests and short-term recurrent BPPV were analyzed. A total of 96 patients with unilateral idiopathic BPPV were included for analysis. The numbers of non-recurrent patients and recurrent patients were 57 (59.4%) and 39 (40.6%), respectively. Only the results of EcochG and the caloric test showed significant differences between non-recurrent and recurrent patients (both P < 0.05). The results of these two tests were also found to be independently predictive of short-term recurrence (both P < 0.05). The non-recurrence rate for patients with normal results in both tests reached up to 78.3%, which was significantly higher than that for patients with abnormal results in both tests, 28.6% (P < 0.05). Endolymphatic hydrops and canal paresis were independent risk factors for short-term recurrent BPPV. Additional treatments should be considered to reduce the recurrence rate, including dehydration treatment and vestibular rehabilitation.

Posterior canal benign paroxysmal positional vertigo with long duration: Heavy or light cupula?

To investigate the characteristics of positional nystagmus in posterior semicircular canal (PSCC) benign paroxysmal positional vertigo (BPPV) patients with longer durations, and to discuss the possible underlying mechanism of this nystagmus. We conducted a retrospective review, and enrolled 118 consecutive patients with unilateral PSCC BPPV. The duration of nystagmus during a Dix-Hallpike test was classified into short (<1 min) and long (≥1 min) durations. For the identification of a neutral point in PSCC BPPV patients with long durations, the patient's head was turned 45° to the lesioned side to set the affected PSCC on the sagittal plane, and the disappearance of positional nystagmus was investigated in a pitch plane. Among 118 patients with PSCC BPPV, positional nystagmus during a Dix-Hallpike test showed short durations (<1 min) in 112 patients and long durations (≥1 min) in 6 patients. Of 6 PSCC BPPV patients with a long duration, a neutral point was identified in 5 patients whose nystagmus lasted for longer than 2 min; interestingly, a neutral point was observed when the patient's head was slightly tilted backward in all 5 patients. Considering that a neutral position was identified when the patient's head was slightly tilted backward while keeping the head turned 45° to the right or left, we assume that the light cupula condition of the ipsilateral PSCC or the contralateral anterior semicircular canal, and not PSCC BPPV cupulolithiasis, could be responsible for the occurrence of persistent torsional-upbeating nystagmus in a Dix-Hallpike test. 4.

Comparison of Repetitive Modified Epley’s manoeuvre in single sitting vs. thrice daily In Refractory Benign Paroxysmal Positional Vertigo.

Introduction: Benign paroxysmal positional vertigo (BPPV) was recognized by Robert Barany in 1921. It is the commonest cause of peripheral vertigo presenting to vertigo clinics. Among several treatment modalities, Epley manoeuvre carries a 90.7-96% cure rate. The modified Epley manoeuvre, a more convenient version and when conducted in the office by a skilled clinician, carries a greater chance of rapid recovery. It may be self-performed at home with a layman assistant.&#x0D; Objective: To compare the efficacy of modified Epley’s manoeuvre performed thrice daily with repetitive single sitting, till resolution of symptoms, in posterior canal benign paroxysmal positional vertigo (BPPV) patients.&#x0D; Methodology: This prospective comparative clinical study was conducted at Niazi welfare foundation teaching hospital, Sargodha from 1st February 2022 to 31st July 2022. 86 patients with refractory unilateral BPPV were included in the study and divided into two groups. Group A (n=44) patients had modified Epley manoeuvre performed repeatedly at intervals in a single sitting till the resolution of nystagmus. For group B (n=42) patients, Modified Epley manoeuvre was performed once in the clinic, followed by thrice daily manoeuvre done at home till the resolution of symptoms. The time to recovery, the improvement in vertigo (no nystagmus) after a week and recurrence rate among the two groups were evaluated.&#x0D; Result: For group A, 61.36% (n=27) patients became symptom-free after 2 attempts, while 100% (n=44) got relief after 5 attempts. For group B the earliest response was seen in 4 patients (9.52%) after 2 days (6 attempts) while 100% improvement (n=42) was seen after 4 days (12 attempts).&#x0D; Conclusion: Repeated modified Epley’s manoeuvre in a single sitting promptly reliev vertigo compared to thrice daily manoeuvres.&#x0D; Keywords: Benign paroxysmal positional vertigo, Nystagmus, Dix-Hallpike manoeuvre, Particle repositioning manoeuvre, Canalith, Modified Epley manoeuvre.&#x0D;

Relationship between stress levels and endolymphatic space volume in Meniere's disease

ObjectivesSince the first report by Hallpike and Yamakawa in 1938, many more patients with Meniere's disease (MD) with endolymphatic hydrops (EHs) have been described. Mental/physical stress and a subsequent increase in the release of the anti-diuretic hormone (ADH) supposedly triggers MD. In the present study, to assess the relationship between stress and EHs, we conducted a series of stress-related questionnaires as well as a 3D endolymphatic space (ELS) analysis in patients with unilateral MD. MethodsWe enrolled 76 patients with unilateral MD (uMD) as the active group and 75 patients with unilateral benign paroxysmal positional vertigo (uBPPV) as the control group; both underwent examinations between June 2014 and November 2019. All patients underwent 3-T magnetic resonance imaging (MRI) 4 h after intravenous gadolinium injection. We used the total fluid space (TFS), ELS, and ELS rate (ELS/TFS × 100), which is the percentage of the volume of the ELS relative to that of the TFS, for a precise evaluation of the ELS and EHs in MD. Stress was evaluated using the Self-Rating Depression Scale (SDS), the psychological Stress Response Scale (SRS), and the modified Dizziness Handicap Inventory (mDHI). Stress scores and blood ADH levels were compared across patient groups. ResultsIn patients with uMD, ELS rates significantly correlated with SRS scores on both the affected and the healthy side and with mDHI scores on the affected side, while the SDS and ADH showed no significant correlation with the ELS rates. Correlations were much stronger in the group with severe SDS and one with low ADH levels. ConclusionsThe present results indicate that stress may be involved in EHs development in uMD, not only in the ipsilateral but also the contralateral ear. They also suggest that patients with neuropsychiatric tendencies may develop EHs and MD in response to a stressful lifestyle.

Spontaneous Nystagmus in Patients With Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo.

This study aimed to investigate the incidence of spontaneous nystagmus (SN) in posterior semicircular canal (PSCC) benign paroxysmal positional vertigo (BPPV) and its effect on treatment outcomes. Retrospective case series. Tertiary referral center. This study included 50 patients with idiopathic unilateral PSCC BPPV between July 2021 and May 2022. The presence of SN was investigated, and the results of the bithermal caloric test and video head impulse test (vHIT) were compared. SN was observed in 13 (26%) of the 50 patients presenting PSCC BPPV. The direction of SN was mainly unidirectional and horizontal in 12 of the 13 patients with a slow-phase velocity ranging from 2 to 4°/s. One patient presented an upbeating torsional SN at the initial evaluation. The mean vHIT gain of the PSCC on the affected side was significantly lower in patients with SN than those without SN (p = .004, Mann-Whitney U test). The proportion of patients who recovered within 2 sessions of the repositioning maneuver was significantly higher in those without SN than that in those with SN (p < .001, Fisher's exact test). This study demonstrated that the treatment outcomes of PSCC BPPV were significantly worse in patients with SN than those without SN. Examining the presence of SN in patients with PSCC BPPV may be helpful in counseling the patients on prognosis, and it is expected that more sessions of canalith repositioning maneuver may be required to treat PSCC BPPV in patients with SN than those without SN.

Bilateral Dysfunction of Otolith Pathway in Patients With Unilateral Idiopathic BPPV Detected by ACS-VEMPs.

ObjectiveTo observe the functional status of the otolith pathway in patients with unilateral idiopathic benign paroxysmal positional vertigo (BPPV) by combining air-conducted sound elicited cervical vestibular-evoked myogenic potential (ACS-cVEMP) and ocular vestibular-evoked myogenic potential (ACS-oVEMP).MethodsOne hundred and eighty patients with BPPV were recruited for conventional cVEMP and oVEMP tests. The abnormal rates of VEMPs were compared between BPPV patients and control participants.ResultsThe abnormal rates of cVEMP and oVEMP in BPPV patients were 46.7% (84/180) and 57.2% (103/180) in affected ears, respectively, and 45.0% (81/180) and 56.7% (102/180) in unaffected ears, respectively; both were significantly higher than the abnormal rates of cVEMP and oVEMP in normal control ears. Compared with normal subjects, the cVEMP response rate was lower in affected and unaffected ears in BPPV patients. The abnormal rates of cVEMP and oVEMP were 48.1% (76/158) and 57.6% (91/158) in patients with posterior semicircular canal BPPV, and 36.4% (8/22) and 54.5% (12/22) in lateral semicircular canal BPPV. There was no significant difference in VEMP abnormalities between posterior semicircular canal BPPV and lateral semicircular canal BPPV.ConclusionThe prevalence of abnormal cVEMPs and oVEMPs in both affected and unaffected ears of patients with BPPV was significantly higher than that observed in the control group. The pathological mechanism of unilateral idiopathic BPPV may be associated with bilateral degeneration of otolith pathways.

The effect of vestibular rehabilitation on balance function and disability of adults with benign paroxysmal positional vertigo of posterior semicircular canals

Background and objective: Benign Paroxysmal Positional Vertigo (BPPV) is known as the most common cause of vertigo. Vestibular rehabilitation is an effective therapeutic option for patients with significant balance problems. The purpose of this study was to evaluate the degree of balance problems caused by BPPV as well as the effect of vestibular rehabilitation exercises on reducing the problems of this group of patients. Methods: In this clinical trial study, 30 patients with posterior semicircular canal BPPV were studied. All patients underwent vestibular rehabilitation therapy using Epley repositioning maneuver method. The effect of balance problem on their quality of life and handicap before and two months after the intervention was assessed using the Dizziness Handicap Inventory (DHI) questionnaire. Results: The handicap degree of the BPPV patients before therapy was at mild level. The highest and lowest scores were related to physical and emotional dimensions of DHI with values of 13.58 and 6.46, respectively. DHI scores significantly decreased following two months therapy (P <0.001). This highest and lowest improvement was observed in functional (mean change: 13.58) and emotional (mean change: 6.46) dimensions, respectively. Conclusion: Vestibular rehabilitation is a beneficial approach for adults with unilateral BPPV of posterior semicircular canals. Through early diagnosis and intervention of vestibular disorders, the disability and handicap experienced by BPPV patients will be significantly reduced. Furthermore, the negative effects of this disease on the physical, functional and emotional aspects of patients will be noticeably diminished.

Gait in Benign Paroxysmal Positional Vertigo.

Purpose: Patients with benign paroxysmal positional vertigo (BPPV) experience gait unsteadiness not only during the attacks but also between the spells. This study aimed to measure gait changes in BPPV and determine whether these changes are associated with the involved canal or lesion side.Methods: We recruited 33 patients with a diagnosis of unilateral BPPV. Patients with other vestibular or central nervous system disorders were excluded. Gait was assessed using the GAITRite™ system before and after canalith repositioning treatment (CRT).Results: After CRT, improvements were observed in various gait parameters including velocity (p < 0.001), cadence (p < 0.001), functional ambulation profile (p = 0.011), and the coefficient of variation of stride time (p = 0.004). Exploration of the center of pressure (COP) distribution also revealed improved stabilization during locomotion after CRT. The spatiotemporal gait variables did not differ between the patients with horizontal- and posterior-canal BPPV, or between the ipsilesional and contralesional sides before CRT.Conclusions: The gait parameters reflecting velocity and rhythmicity along with stability of COP distribution improved after the resolution of BPPV. Episodic overexcitation of semicircular canal may impair the vestibular information that is integrated with the other reference afferent systems and lead to impaired gait performance.

Incidence of unilateral and bilateral benign paroxysmal positional vertigo when the left and right Dix-Hallpike manoeuvres are positive: a model based on the sense of torsional nystagmus

SUMMARYPatients presenting with nystagmus indicative of benign paroxysmal positional vertigo (BPPV) during the left and the right Dix-Hallpike manoeuvres (DHMs) are frequently seen in clinical practice. In such cases, BPPV may be unilateral or bilateral. The aim of this study is to describe the incidence of unilateral and bilateral BPPV when both DHMs are positive, taking into account the sense of the torsional component of nystagmus. This is a prospective multicentre study. BPPV patients were classified into three groups: patients with only one positive DHM (control group, CG), patients showing positive bilateral DHM with nystagmus in the same sense in both DHMs (same sense group, SSG) and patients showing positive bilateral DHM with the torsional component of nystagmus beating in opposite senses in each DHM (opposite sense group, OSG). Only one Epley Manoeuvre (EM) was performed on all patients. Based on the ipsilateral result of the EM, the contralateral result of the same EM and the BPPV resolution rate in the control group, a model was developed to predict the incidence of unilateral and bilateral BPPV in the SSG and the OSG. There were 234 patients in the control group, 20 in the SSG and 23 in the OSG. The model estimated that the percentage of unilateral BPPV would be 89.5% in SSG and 38.7% in OSG. Using these findings, we conclude that when both DHMs are positive, BPPV may be unilateral or bilateral. If the torsional components of both nystagmuses beat in the same sense, it is more likely to be unilateral BPPV. If the torsional components beat in opposite senses, both situations can be considered equally likely.

Evaluation of utricular and saccular function in BPPV patients: The role of VEMP in diagnosis

Aim: The pathological cause of Benign Paroxysmal Positional Vertigo (BPPV) is the degeneration of the otolith organs (utricle and sacculus). Vestibular Evoked Myogenic Potentials (VEMP) assess the functions of the otolith organs. The objective of this research was to evaluate the otolith organ functions of patients with unilateral idiopathic BPPV (canalolithiasis of the posterior and lateral semicircular canals) by cVEMP and oVEMP tests. Material and Methods: The study prospectively included 35 patients with BPPV (canalolithiasis of the posterior and lateral semicircular canals) and 30 healthy individuals. Bilateral cVEMP and oVEMP tests were administered to all participants. Participants were divided into three groups: control, BPPV-affected ear, and unaffected ear.Results: In our study, cVEMP and oVEMP abnormalities were statistically significantly different both between the affected and unaffected ear groups and between the affected ear and control groups. There were statistically significant differences in the cVEMP and oVEMP amplitude values both between the affected and unaffected ear groups and between the affected ear and control groups. Also, the asymmetry ratios of the cVEMP and oVEMP tests were statistically significantly different between the case group and the control group. The cVEMP and oVEMP wave latencies (p1, n1, p1-n1) were not statistically significantly different among the BPPV-affected ear, unaffected ear, and control groups. The results of measurements were not statistically significantly different between the posterior and lateral canal involvement subgroups of BPPV patients.Conclusion: Abnormal cVEMP and oVEMP test results, which are observed more frequently in patients with BPPV compared to the control group, indicate utricular and saccular degeneration. Higher oVEMP abnormality ratios compared to those of cVEMP in BPPV patients suggest that utricular dysfunction may be more common than saccular dysfunction.

Causes of Persistent Positional Vertigo Following Posterior Semicircular Canal Occlusion for Benign Paroxysmal Positional Vertigo.

To report causes of persistent recalcitrant positional vertigo (PRPV) after posterior semicircular canal occlusion (PSCO) for benign paroxysmal positional vertigo (BPPV). Retrospective chart review. Single high-volume otology practice. Patients diagnosed with BPPV from 2007 to 2017. PSCO and follow-up care including diagnostic and particle repositioning maneuvers for recurrent BPPV. PRPV, defined as recalcitrant positional vertigo for any reason following PSCO. Twenty seven PSCO operations were performed in 26 patients. Twenty five patients (96.2%) had resolution of the Dix-Hallpike test in the operated ear. Eleven patients (42.3%) developed BPPV postoperatively, three (11.5%) in the operated ear and eight (30.8%) in the contralateral ear. Five of eight patients (62.5%) who developed contralateral BPPV had unilateral BPPV preoperatively. Eight patients (30.8%) developed BPPV at least twice after surgery or did not resolve, qualifying as PRPV, and all but one of these events occurred in the nonsurgical ear. No instances of cerebrospinal fluid leak, postoperative infection, facial palsy, clinically significant hearing loss, or death occurred. PSCO is a safe and effective option for recalcitrant BPPV. However, 30.8% of patients, including patients with initially unilateral BPPV, had recalcitrant positional vertigo postoperatively, usually due to contralateral BPPV. Patients considering PSCO should be counseled regarding this risk to ensure realistic expectations.

Vertigo returning to the sitting position after the Semont manoeuvre. Is it a prognostic symptom?

Benign paroxysmal positional vertigo (BPPV) is a frequent benign vestibular condition usually managed with particle repositioning manoeuvres, such as Semont manoeuvre (SM). Since few authors have described prognostic aspects of liberatory manoeuvres, the purpose of the present study was to investigate the possibility of considering vertigo in the final sitting position of the SM as a prognostic symptom in the outcome of posterior BPPV. One hundred and thirteen patients with diagnosis of unilateral posterior BPPV were taking into account in our retrospective cohort study: 41 men and 72 women, aged 22 to 85 years. All were submitted to one repositioning SM and afterwards controlled 3 to 5 days later by means of an additional Dix-Hallpike manoeuvre. The main outcomes investigated were the occurrence of Ny and vertigo in the different phases of the SM, as well as their characteristics in relation to outcome of the disease. Among all patients, 75 (66%) presented both orthotropic Ny and vertigo in the second SM position and 72% obtained a complete resolution of the disease after the liberatory manoeuvre. Contrarily, 17 subjects (15%) manifested vertigo in the final sitting position of the SM and among these, only 7 (41%) completely recovered from BPPV. According to our data, in case of sudden vertigo returning to the final sitting position of the SM, the failure rate of the liberatory manoeuvre was higher, even though not statistically significant: therefore, it can be considered as a negative prognostic factor of posterior BPPV after SM.

What Is the Prognosis of Patients with Benign Paroxysmal Positional Vertigo in Sudden Sensorineural Hearing Loss?

Objectives Vertigo is considered a poor prognostic factor in patients with sudden sensorineural hearing loss (SSNHL). Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo and may accompany SSNHL. However, whether BPPV is a poor prognostic factor remains controversial. We identified features of prognostic utility in patients with both SSNHL and BPPV. Methods We retrospectively evaluated data on all patients diagnosed with SSNHL at Keimyung University Dongsan Medical Center between January 2011 and December 2015. We reviewed medical records, the results of vestibular function testing, and audiographic data. Results Of the 524 idiopathic SSNHL patients, 20 (3.8%) were also diagnosed with unilateral BPPV. The average pure tone average (PTA) of those with both SSNHL and BPPV was higher than that of those without BPPV. Of the 471 patients with SSNHL only, 143 (30%) exhibited complete recovery. Of the 33 SSNHL patients with vertigo, 3 (9%) exhibited complete recovery, but only 3 (15%) of those with both SSNHL and BPPV exhibited complete recovery. Of the 20 patients with both SSNHL and BPPV, 15 had ipsilateral BPPV and 5 contralateral BPPV. Conclusions Patients with BPPV had a higher average initial PTA score and poorer hearing recovery after treatment, than patients with SSNHL alone. Patients with contralateral BPPV had a somewhat better prognosis than those with ipsilateral BPPV, but statistical significance was not attained. Keywords: Benign paroxysmal positional vertigo; Hearing loss 중심 단어: 현훈, 양성돌발성체위성현훈, 난청

Is Alteration of Tuning Property in Cervical Vestibular-Evoked Myogenic Potential Specific for Ménière’s Disease?

The aim of this study is to show sensitivity and specificity of cervical vestibular-evoked myogenic potential (cVEMP) tuning property test to Ménière's disease (MD) in comparison with healthy controls (HC) and patients with other vestibular diseases. Totally 92 subjects (50 women and 42 men, 20-77 years of age) were enrolled in this study. Subjects were composed of 38 definite unilateral MD patients, 11 unilateral benign paroxysmal positional vertigo patients, 14 vestibular migraine patients, 19 unilateral vestibular neuritis patients, and 10 HC. The subjects underwent cVEMP testing to 500 and 1,000 Hz short tone bursts (125 dBSPL). The corrected amplitudes of the first biphasic responses (p13-n23) (cVEMP) were measured. Then, a tuning property index (the 500-1,000 Hz cVEMP slope) was calculated. The area of under the ROC curve (AUC) was 0.75 in comparison with other vestibular disease patients, while AUC was 0.77 in comparison with other vestibular disease patients plus HC. The best cutoff point of the 500-1,000 Hz cVEMP slope was -19.9. Sensitivity of the tuning property test to MD was 0.74, while specificity was 0.76 to other vestibular disease patients. The tuning property test of cVEMP is useful as a screening test of MD.

Utility of the Frequency Tuning Measure of oVEMP in Differentiating Meniere's Disease from BPPV.

Utility of frequency tuning of ocular vestibular evoked myogenic potential (oVEMP) for evaluation of utricular function in individuals with Meniere's disease is a recent development. However, there is dearth of studies regarding its utility in differential diagnosis of Meniere's disease from other vestibular pathologies. The present study aimed at investigating the feasibility of frequency tuning of oVEMP in discriminating Meniere's disease from benign paroxysmal positional vertigo (BPPV). Static group comparison. oVEMPs were acquired from 36 individuals, each with unilateral Meniere's disease and unilateral BPPV. Thirty-six age- and gender-matched healthy individuals formed comparison group for each of the two clinical groups. Contralateral oVEMPs were recorded from both ears of all the participants. The responses pertaining to octave and mid-octave frequencies from 250 to 4000 Hz, one frequency presented at a time, were recorded from infra-orbital electrodes (noninverting placed 1 cm below the lower eyelid and inverting 2 cm below the inverting on the cheek) with forehead as ground. Starting intensity was 125 dB peSPL with subsequent reductions in 10-dB steps to arrive at threshold. The stimuli were delivered to the ear at a rate of 5.1 Hz. The frequency corresponding to the largest peak-to-peak amplitude, best threshold, and/or largest peak-to-peak amplitude at thresholds was considered as the tuning frequency. Proportions of ears with frequency tuning at a particular frequency were compared between the groups. The frequency tuning at 1000 Hz was found to exist in a significantly higher proportion of affected ears with Meniere's disease than the comparison group as well as ears with BPPV (p < 0.05). Using a criterion point of frequency tuning at 875 Hz, the sensitivity and specificity for identifying Meniere's disease was found to be 68% and 100%, respectively. The shift in frequency tuning is an efficient parameter for not only discriminating Meniere's disease from healthy individuals but also distinguishing it from BPPV. Therefore, frequency tuning is recommended as a test parameter of oVEMP for identification of Meniere's disease.

Calcium Homeostasis During Attack and Remission in Patients With Idiopathic Benign Paroxysmal Positional Vertigo.

To evaluate changes in calcium metabolism in patients with idiopathic benign paroxysmal positional vertigo (BPPV) on initial presentation and at the follow-up visit. The study comprised a total of 31 patients aged greater than 18 years who presented at the otorhinolaryngology outpatient clinic of our hospital, newly diagnosed as idiopathic BPPV based on the history compatible with BPPV and positive provocative maneuver (either Dix-Hallpike or Roll test). The first blood sample was obtained on the day of initial presentation when the patient was found to have active unilateral BPPV. After 6 months, a blood sample was again drawn in accordance with the procedure. Blood samples were analyzed for data on 25-hydroxyvitamin D (25(OH)-D), total calcium, parathormone and ionized calcium on initial presentation, and at the follow-up visit. The patients comprised 20 (64.5%) women and 11 (35.5%) men with a mean age of 49.78 years (range, 23-75 years). During an attack a higher prevalence of decreased serum Vitamin D is less than 20 ng/ml, was determined (93.5% versus 38.7%). There were statistical differences between the Vitamin D values, parathormone, and corrected by pH ionized calcium in both periods (p < 0.05). A statistically significant association was determined between Vitamin D and calcium metabolism in patients with idiopathic BPPV. It can be considered that Vitamin D deficiency and decreased ionized Ca level may be a risk for BPPV, not only in patients with osteoporosis but also in all patients. Very low levels of 25(OH)-D seem to be associated with recurrence of BPPV. The recurrences might possibly be prevented with supplementary Vitamin D especially in those with recurrent idiopathic BPPV but further studies would be necessary to determine this.

Effects of postural restriction after modified Epley maneuver on recurrence of benign paroxysmal positional vertigo.

In the present study, we calculated the success rate of the modified Epley maneuver and determined the effectiveness of post-maneuver positional restriction in terms of the prevention of early and late recurrence. The present study was conducted on 78 patients who had unilateral benign paroxysmal positional vertigo (BPPV) of the posterior semicircular canal (SCC) and who were treated in the Otorhinolaryngology Department of Susehri State Hospital. The Dix-Hallpike test was performed on all patients. After the involved canal was identified using this test, we guided patients through the modified Epley repositioning maneuver. A maximum of two maneuvers were performed in the same session. The patients were randomly divided into two groups. One group was not advised any positional restriction, while the second group was advised positional restriction for 10 days after the procedure. Recurrences during 1-90 days after the treatment were noted as early recurrences, while those that occurred after 90 days were noted as late recurrences. In the restriction group (n=39), repositioning was successful after a single maneuver in 32 (82.05%) patients and after two maneuvers in 5 (12.8%) patients. Repositioning failed in two (5.1%) patients. In the non-restriction group (n=39), repositioning was successful after a single maneuver in 31 (79.4%) patients and after two maneuvers in 6 (15.3%) patients. Repositioning failed in two (5.1%) patients. Thus, the success rate was 94.8% in each group. Early recurrence occurred in 3 (8.1%) of 37 patients in the restriction group and 2 (5.4%) of 37 patients in the non-restriction group (p>0.05). Late recurrence occurred in 5 (13.5%) of 37 patients in both the restriction and non-restriction groups (p>0.05). Postural restriction after a canalith repositioning procedure does not improve procedural success or decrease early and late recurrence rates. However, the number of patients was too small to detect a difference between both treatment groups.

Sudden hearing loss with simultaneous posterior semicircular canal BPPV: Possible etiology and clinical implications

ObjectivesThe objectives of this study were to describe the clinical course and outcome of patients with sudden sensorineural hearing loss (SSNHL) in conjunction with benign paroxysmal positional vertigo (BPPV), and hypothesize the possible pathophysiology of this entity. Study designRetrospective study of all patients with evidence of SSNHL with any type of BPPV between 2008 and 2012. SettingsTertiary care university hospital. Subjects and methodsFive patients aged 56 to 71 were diagnosed with unilateral profound SSNHL and BPPV. Neurotologic examination revealed an ipsilateral torsional, up-beating nystagmus on Dix–Hallpike exam. Severe or profound ipsilateral–sensorineural hearing loss was recognized on audiometry. The rest of the exam was normal; this was in keeping with the diagnosis of SSNHL with ipsilateral posterior semicircular canal BPPV. ResultsAll patients were treated with a modified Epley maneuver; oral steroids were administered for two weeks. In all cases vertigo resolved and the Dix–Hallpike exam became normal within several weeks. However, the hearing loss remained unchanged in two patients. Magnetic resonance imaging of the head was normal and ENG caloric test demonstrated mild ipsilateral canal paresis in two patients. Conclusions1. Patients with SSNHL and BPPV can have a variable clinical course and outcome. This entity may be quite common, but the diagnosis of BPPV can be missed if a complete neurological physical examination is not performed. 2. Arterial occlusions or selective multiple vascular or neural involvement may explain the pathophysiology of SSNHL with BPPV of the posterior semicircular canal.