Influence of Fatigability on the Timing of Reassessment in the Treatment of Posterior Canal Benign Paroxysmal Positional Vertigo / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The early assessment of treatment is not done for benign paroxysmal positional vertigo (BPPV) since the well-known phenomenon of fatigability after a repeated positional test can mimic successful treatment. The aim of this study is to evaluate the clinical implication of ‘fatigability’ after Epley maneuver and to identify the therapeutic efficacy of Epley maneuver in posterior canal BPPV (PC-BPPV). SUBJECTS AND METHOD: This study was prospectively conducted by two dizziness clinics on 51 consecutive patients diagnosed with PC-BPPV. All patients included in the study received Epley maneuver treatment. The therapeutic results were reassessed immediately after a single trial of Epley maneuver. After 30 minutes, results were reassessed repeatedly to confirm the fatigability of diagnostic procedure immediately after treatment. If the treatment was not successful after 30 minutes, Epley maneuver was repeatedly performed until complete resolution. RESULTS: Immediately after the first maneuver, 45 of 51 (88.2%) patients had neither vertigo nor nystagmus during the positional test. All patients demonstrated complete resolution after receiving one to three Epley maneuvers on the day of diagnosis. ‘Fatigability (false negative result)’ was confirmed for only one case (1 of 6 patients, 16.7%), in which nystagmus was observed after 30 minutes but not identified immediately after the first Epley maneuver. CONCLUSION: The therapeutic efficacy of Epley maneuver is very high in PC-BPPV. Considering the possibility of fatigability when reassessment is performed immediately after therapeutic maneuver, clinicians should avoid assessing the outcome immediately after treatment in patients with PC-BPPV.

A Case of Middle Ear Implantation Using the Vibrant Soundbridge in a Patient with Bilateral Mixed Hearing Loss / 대한이비인후과학회지

It is challenging to achieve sufficient hearing gain in patients with mixed hearing loss. In chronic middle ear diseases, conventional passive reconstructive surgeries often result in suboptimal hearing gain and additional hearing aids may have limitations due to insufficient sound amplification, occlusion effect, acoustic feedback, and skin irritation. Middle ear implantation (MEI) using Vibrant Soundbridge (VSB) is another option for auditory rehabilitation in mixed hearing loss as well as sensorineural hearing loss. The floating mass transducer of VSB can be placed on various middle ear structures either directly or using different types of couplers in order to deliver vibratory mechanical energy to the cochlea. We report a patient who presented with bilateral mixed hearing loss due to chronic otitis media and had limitations using conventional hearing aids in the worse hearing ear. The patient was successfully treated with MEI using the Bell coupler together with middle ear surgery in a single step.

Pseudo-Spontaneous Nystagmus and Head-Shaking Nystagmus in Horizontal Canal Benign Paroxysmal Positional Vertigo / 대한평형의학회지

OBJECTIVES: The purpose of this study was to examine the clinical manifestations and significance of pseudo-spontaneous nystagmus (PSN) and head-shaking nystagmus (HSN) in horizontal canal benign paroxysmal positional vertigo (HC-BPPV). METHODS: Two hundred fifty-two patients diagnosed as HC-BPPV were reviewed retrospectively. After excluding 55 patients with ipsilateral vestibular diseases, multiple canal BPPV, or those who were lost to follow-up, we analyzed the direction of PSN and HSN in patients with HC-BPPV. We also compared the clinical characteristics and treatment outcome between PSN-positive and PSN-negative groups. RESULTS: Our study included 197 patients composed of 80 patients with geotropic HC-BPPV and 117 patients with apogeotropic HC-BPPV. PSN was observed in 13.7% patients and HSN was observed in 45.2%. The incidence of HSN was higher in apogeotropic HC-BPPV, while the proportion of PSN was not statistically significant between the two subtypes. There was no directional preponderance in geotropic HC-BPPV, while ipsilesional PSN and contralesional HSN showed higher incidence in apogeotropic HC-BPPV. The dizziness handicap inventory score in the PSN-positive group was higher than that in the PSN-negative group (p<0.001), and the duration of symptom onset in the PSN-positive group was shorter than that in the PSN-negative group (p=0.047). However, there was no significant difference in the treatment outcome between the two groups. CONCLUSIONS: The incidence of HSN was higher than that of PSN in patients with apogeotropic HC-BPPV. Patients with HC-BPPV showing PSN demonstrated more severe initial symptoms and visited the hospital in a shorter period of time after the onset of symptoms.

A Patient with Sudden Hearing Loss with Vertigo Showing Exclusive Posterior Semicircular Canal Abnormality / 대한평형의학회지

It is known that about 30% of patients with sudden hearing loss present with vertigo or dizziness. In clinical practice, this is called sudden hearing loss with vertigo (SHLV) although definite diagnostic criteria have not been established. Dizziness in SHLV is known to be caused by the dysfunction of the vestibular end-organs as well as the superior vestibular nerve or both vestibular nerve divisions. Lesions of the inferior vestibular nerve or a single semicircular canal have also been reported in these patients. Herein we report a 71-year-old male patient with SHLV who demonstrated vestibular dysfunction involving only the posterior semicircular canal. The patient showed normal results in the bithermal caloric test and the cervical vestibular evoked myogenic potentials test as well as positional test. Video head impulse test showed decreased gain only in the posterior semicircular canal. This case is significant in showing that dizziness in SHLV patients can occur by an abnormality involving only a single semicircular canal.

Compensation of the Postural Instability in Patients with Acute Unilateral Vestibular Neuritis: The Usefulness of Computerized Dynamic Posturography as an Objective Indicator / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The aim of this study was to evaluate the usefulness of computerized dynamic posturography (CDP) in patients with acute vestibular neuritis (AVN) by identifying the recovery period of Sensory Organization Test (SOT) and comparing the result of SOT with those of the vestibulo-ocular reflex (VOR) tests and subjective symptoms. SUBJECTS AND METHOD: A prospective study was conducted on 41 patients who were diagnosed with AVN. The SOT was measured daily until the equilibrium composite score recovered the normal value. A survey, composing of questionnaires on Visual Analogue Scale (VAS), Dizziness Handicap Inventory (DHI), motion sensitive quotient (MSQ) and Activities-Specific Balance Confidence Scale (ABC), was conducted on the patient's initial visit and on the day the normal value of SOT was recovered. Videonystagmography and the caloric test were also performed, and the results were compared with those of the SOT. RESULTS: The mean duration from the onset of vertigo to the recovery of SOT scores was 3.7±2.9 days (median 3.0 days) and that from the onset of vertigo to the disappearance of spontaneous nystagmus was 17.1±27.2 days (median 6.0 days). The scores of 4 questionnaires (VAS, DHI, MSQ, and ABC) were significantly different between the initial day and the day of recovery to the normal value of SOT (p<0.001). However, the velocity of spontaneous nystagmus on the initial visit and the degree of canal paresis from the caloric test showed no significant correlations to recovery duration from the onset of vertigo to the normalization of SOT score. CONCLUSION: The recovery duration of vestibulospinal reflex (VSR) is much shorter than that of VOR in patients with AVN. The recovery of subjective symptoms showed close correlation with the recovery of VSR, but the results of VSR was not correlated with that of VOR. Therefore, CDP could be a very useful test for monitoring the resolution of subjective symptoms in patients with AVN.

The Influence of Sleep Position on Benign Paroxysmal Positional Vertigo / 대한평형의학회지

OBJECTIVE: The purpose of this study was to identify the influence of sleep position on benign paroxysmal positional vertigo (BPPV). METHODS: Four hundred sixty patients diagnosed as posterior or horizontal canal BPPV were analyzed retrospectively. All patients were asked about their preferred sleep positions among the following four choices: supine, right or left lateral, or no predominant side via questionnaire at initial visit and after 1month. Patients were classified into two groups: affected side group meaning that the patient preferred to sleep ipsilateral to the affected ear and other position group including all positions other than lying lateral to the affected side after treatment. We analyzed the change in the sleep pattern after treatment and compared the recurrence rate between the two groups. RESULTS: Our study included 244 patients with posterior canal BPPV (PC-BPPV) and 216 patients with horizontal canal BPPV (HC-BPPV). Statistically significant correlation was demonstrated between sleep position side and the affected side by BPPV. The number of patients who slept on the affected side by BPPV decreased, while the number of patients who slept on the healthy side increased significantly after treatment. There was no statistically significant difference in the recurrence rate between the two groups. CONCLUSION: There was significant correlation between the sleep position side and the affected side in PC-BPPV and HC-BPPV. The patient had a tendency to avoid lying lateral to the affected side by BPPV during sleep after treatment, however the change in sleep position did not influence the recurrence rate of BPPV.

Various Nystagmus Patterns and Their Clinical Significance in Benign Paroxysmal Positional Vertigo of Anterior Semicircular Canal / 대한평형의학회지

OBJECTIVE: The purpose of this study was to identify the diverse patterns of nystagmus and analyze their clinical significance in benign paroxysmal positional vertigo (BPPV) of the anterior semicircular canal. METHODS: Fifty-three patients diagnosed with anterior canal BPPV (AC-BPPV) were analyzed retrospectively. Patients were classified according to the presence or absence of the torsional component of the nystagmus and the direction of Dix-Hallpike test which induced the nystagmus. We compared the clinical characteristics and treatment outcomes among the different patient groups. RESULTS: There were 11 patients with unilateral down beat (DB) nystagmus, 11 patients with bilateral DB nystagmus, 14 patients with ipsilateral torsional down beat (TDB) nystagmus, 7 patients with contralateral TDB nystagmus, and 7 patients with bilateral TDB nystagmus. There were no differences between the unilateral and the bilateral DB groups in terms of the duration of nystagmus or vertigo and the number of treatment sessions. In addition, the ipsilateral TDB group showed no significant clinical difference compared to the contralateral or bilateral TDB group. CONCLUSION: Various nystagmus patterns can be seen in AC-BPPV. There was no statistically significant difference in the clinical characteristics according to the different nystagmus patterns. This information may be helpful for clinicians in counseling and managing the patients with AC-BPPV.

Clinical Characteristics of Horizontal Canal Benign Paroxysmal Positional Vertigo with Persistent Geotropic Direction Changing Positional Nystagmus / 대한평형의학회지

OBJECTIVE: The purpose of this study was to identify the clinical characteristics of horizontal canal benign paroxysmal positional vertigo (h-BPPV) with persistent geotropic direction changing positional nystagmus (DCPN). METHODS: One hundred thirty two patients diagnosed as the geotropic subtype of h-BPPV were analyzed retrospectively. Patients were classified into two groups: persistent h-BPPV (ph-BPPV) group which means h-BPPV showing persistent (>1 minute) geotropic DCPN and short duration h-BPPV (sh-BPPV) group that means h-BPPV with short duration (< or =1 minute) geotropic DCPN. We compared the clinical characteristics and treatment outcomes between the two groups. RESULTS: The study included 34 patients with ph-BPPV and 98 patients with sh-BPPV. There were no differences between the two groups in age, distribution of sex and the affected side. The ph-BPPV group had higher secondary BPPV preponderance and dizziness handicap index (DHI) score compared to the sh-BPPV group. The ph-BPPV group required higher number of canalith repositioning procedures (CRPs) until resolution and higher multiple/single CRP ratio than the sh-BPPV group. In addition, the ph-BPPV group showed longer duration until the remission of subjective symptoms (vertigo, dizziness) compared to the sh-BPPV group. CONCLUSION: ph-BPPV was more frequently associated with secondary causes of BPPV and demonstrated higher DHI score, total number of CRP, and longer remission duration of subjective symptoms compared to sh-BPPV. This information may be helpful for clinicians in counseling and managing the patients with persistent geotropic DCPN h-BPPV.