The clinical findings to notice mild elevation of intracranial pressure in an otology clinic.

Mildly elevated intracranial pressure appears to be a distinct pathology separate from idiopathic increased intracranial pressure and migraine. Many patients present with head fullness-pressure and dizziness, which is often suggestive of a clinical diagnosis of vestibular migraine. These patients may additionally have episodic vertigo as seen in endolymphatic hydrops and positional vertigo in addition to feeling dizzy. In most cases, hearing is normal. A long duration of the condition or a presence of associated ear pathologies, i.e., dehiscence, fistula, hypermobile footplate, or history of chronic ear infections can add hearing loss to clinical presentations. Low-pitch pulsatile tinnitus, when present, is an important symptom. The neuroimaging findings such as partially empty sella, blockage of the dural venous sinus or sigmoid sinus wall defects are frequently observed. The condition is diagnosed by measuring the lumbar puncture opening pressure. Typically, patients have normal cerebrospinal fluid chemistry and microscopy. Lowering the pressure during the lumbar puncture will resolve the patient's symptoms temporarily. Medical therapy is typically successful using carbonic anhydrase inhibitors and corrections of medical disorders that may be contributing to the increased pressure. A few require shunting or stenting procedures. In this review article, we define the condition in detail with illustrative cases that we collected from our practices.

Physical Therapy for Benign Positional Vertigo of Posterior Canal: The Role of Alternated Epley and Semont Maneuvers.

OBJECTIVE: To investigate if alternated Epley (EP) and Semont (ST) maneuvers could be more effective than repetition of the same in benign paroxysmal positional vertigo of posterior semicircular canal (pBPPV). DESIGN: We retrospectively reviewed the outcome of pBPPV patients treated with a second maneuver for the persistence of positional nystagmus. STUDY SAMPLE: Forty-seven patients underwent 2 STs, 64 with 2 EPs, and 71 EPs followed by ST. Videonystagmography and Dizziness Handicap Inventory (DHI) questionnaire were performed. RESULTS: Absence of positional nystagmus was achieved after 2 maneuvers in 136 patients with pBPPV: 65.9% in the ST group, 70.3% in the EP group, and 84.5% in the EP-ST group. Alternated EP and ST were significantly more effective than repeated ST (P = .03), while we found no significant difference when compared with repeated EP (P = .07). At 1-month follow-up, 12 patients showed persistent positional nystagmus without difference between groups. After 1 month, the 46 patients with negative outcome had significantly higher DHI values (P = .01) than other 136 patients with pBPPV. CONCLUSIONS: Alternated EP and ST seemed more effective than repeating the same maneuver in treating pBPPV, and this should be confirmed in prospective clinical studies. Resolution of nystagmus after maneuvers was fundamental to reduce handicap deriving from dizziness as reported in DHI.

Clinical characteristics of benign paroxysmal positional vertigo in the oldest old / 中华全科医师杂志

Objective:To analyze the clinical characteristics of benign paroxysmal positional vertigo (BPPV) in the oldest old.Method:The clinical data of elderly patients (≥60 years old) with BPPV diagnosed in the Clinical Center for Vertigo and Balance Disturbance of Capital Medical University between January 2019 and October 2021 was collected, including basic information, clinical symptoms in a structured medical history questionnaire and the time interval from the appearance of symptoms to medical consultation. According to the age, patients were divided into elderly group (60-74 years old) and the oldest old group (≥75 years old), and the demographic information, clinical symptoms and consultation time were compared between the two groups.Results:A total of 3 019 patients with BPPV were included in analysis; there were 415 patients in the oldest-old group with the age of (79.54±3.62) years, and 2 604 patients in the elderly group with the age of (65.59±3.88) years. The incidence of vertigo, dizziness or vertigo triggered by position changes of head or body, headache and autonomic symptoms in the eldest-old group were less common than that in the elderly group (all P<0.05). But hearing loss and other types of dizziness (unable to determine the nature of dizziness or vertigo, or without typical symptoms such as dizziness, balance disorders, or instability) were more common in the eldest-old group than those in the elderly group (all P<0.05). Among 3 019 patients, 1 137 had definite time from symptom onset to diagnosis (1 004 in the elderly group and 133 in the oldest-old group), the proportion of patients with the time from the onset to diagnosis>7 days in the oldest-old group was higher than that in the elderly group ( P<0.05). Conclusion:The oldest old patients with BPPV have more atypical symptoms than the younger elderly patients.

Clinical significance of video head impulse test in benign paroxysmal positional vertigo: a meta-analysis.

PURPOSE: To document the effect of cupula deflection in Benign Paroxysmal Positional Vertigo (BPPV) through the measured Vestibulo-Ocular Reflex (VOR) gain in individual semi-circular canals. METHODS: A literature search using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed on December 30, 2020. The following terms were entered in the title, abstract, and keywords in the electronic databases of PubMed, Scopus, Web of Science, and Cochrane Library search engines in different combinations: "Benign Paroxysmal Positional Vertigo" or "Benign Positional Vertigo" or "BPPV," and "Video Head Impulse" or "vHIT". All types of studies were included in the initial search. An additional inclusion criterion was the presence of numerical values of VOR gains of the tested canals in the reports. RESULTS: A total of 122-screened articles were obtained from the electronic database search. Finally, the authors settled on five original articles for meta-analysis with a total of 168 patients (123 with posterior canal BPPV, 28 with lateral canal BPPV, and 17 with anterior canal BPPV) and 85 controls. The main outcomes of these studies comprised the VOR gains of the lateral, posterior, and anterior SCCs on the affected side relative to that in the contralesional side, and/or healthy controls. CONCLUSION: This meta-analysis shows that vHIT can be valuable as a supporting test in the diagnosis of BPPV, especially for posterior canal BPPV.

Treatment of horizontal canal BPPV-a randomized sham-controlled trial comparing two therapeutic maneuvers of different speeds.

OBJECTIVES: To compare the effect of a high-speed barbecue maneuver with the modified Lempert maneuver and sham in patients with benign paroxysmal positional vertigo (BPPV) of the horizontal canal. METHODS: Randomized sham-controlled, single blinded multicenter clinical trial in two university hospitals investigating consecutive patients with horizontal canal BPPV.Patients were randomly assigned to high-speed barbecue (HSB), modified Lempert maneuver (ML), or sham maneuver (SM). All treatments were performed in a biaxial rotational chair with weekly follow-up to a maximum of three treatment sessions. The final follow-up was 3 months after the last treatment. RESULTS: Primary outcome: 2-week recovery rate per protocol. Secondary outcome: Cumulative recovery rate and Dizziness Handicap Inventory (DHI) scores after 3 months per protocol (HSB and ML) and intention to treat (all groups).Fifty-four patients were analyzed after 2 weeks (HSB = 17; ML = 20; SM = 17). Two-week recovery rate was 14/17 after HSB, 11/20 after ML, and 4/17 after SM, with significantly better recovery in HSB [OR 15.17, 95% CI (1.85, 124.63), P = .001] using sham as base level. Recovery rate after 3 months was 15/17 after HSB and 15/19 after ML. Cumulative recovery rate showed no significant differences between the two treatment groups [95% CI (0.30, 13.14), P = .46] in cure rate DHI [95% CI (-16.56, 15.02), P = .92]. No unexpected adverse events were observed. CONCLUSION: Velocity change in horizontal canal BPPV treatment gives a faster initial recovery. Rapid recovery could reduce the disease burden. TRIAL REGISTRATION: Clinicaltrials.gov. Identifier: NCT01905800. LEVEL OF EVIDENCE: 1b.

Cardiovascular Risk Factors and Benign Paroxysmal Positional Vertigo in Community Otolaryngology-Head and Neck Surgery.

OBJECTIVE: Cardiovascular risk factors have been associated with benign paroxysmal positional vertigo (BPPV), possibly causing degeneration of the utricular epithelium and subepithelium, but supportive evidence is mixed. This is the first study to examine the association between cardiovascular risk factors and BPPV as they present in the community practice of comprehensive otolaryngology-head and neck surgery. STUDY DESIGN: Cross-sectional case-matched case-control series. SETTING: A community practice of otolaryngology-head and neck surgery with 3 clinical offices and a socioeconomically diverse patient population. SUBJECTS AND METHODS: Clinical data were collected retrospectively from the electronic health records of a continuous 4-year series of 628 patients with BPPV and age- and sex-matched controls. RESULTS: There were no statistically significant associations found between BPPV and diabetes, hypertension, dyslipidemia, or body mass index in the study population in pairwise comparisons or multivariable modeling. CONCLUSION: This study suggests that BPPV as encountered in a community ear, nose, and throat practice is not generally associated with cardiovascular risk factors. The possibility that these or other cardiovascular risk factors may be causative in some cases cannot be excluded, though most cases of BPPV appear to be caused primarily by shedding of otoconia from the utricle that is idiopathic or at least in part by unconfirmed noncardiovascular factors.

Dizziness demystified.

Four vestibular presentations caused by six different disorders constitute most of the neuro-otology cases seen in clinical practice. 'Acute vestibular syndrome' refers to a first-ever attack of acute, spontaneous, isolated vertigo and there are two common causes: vestibular neuritis / labyrinthitis and cerebellar infarction. Recurrent positional vertigo is most often caused by benign paroxysmal positional vertigo and less commonly is central in origin. Recurrent spontaneous vertigo has two common causes: Ménière's disease and vestibular migraine. Lastly, chronic vestibular insufficiency (imbalance) results from bilateral, or severe unilateral, peripheral vestibular impairment. These six disorders can often be diagnosed on the basis of history, examination, audiometry, and in some cases, basic vestibular function testing. Here we show that most common neuro-otological problems can be readily managed by general neurologists.

A comparison of benign positional vertigo and stroke patients presenting to the emergency department with vertigo or dizziness.

PURPOSE: To compare imaging utilization between patients presenting to the emergency department (ED) with vertigo and dizziness (VDS) who are diagnosed with stroke and benign paroxysmal positional vertigo (BPPV). METHODS: All patients presenting to the ED with VDS (January 2014-June 2018) were identified. Those with a discharge diagnosis of stroke and BPPV were analyzed. RESULTS: 17,884 patients presented to with VDS. 452 were diagnosed with BPPV and 174 with acute stroke. 55.7% of stroke patients had at least one neurologic symptom beyond VDS, 63.8% had a positive neurologic exam, and 80.5% had either; 90.2% had at least one stroke risk factor (RF). 42.0% of BPPV patients received imaging, of which 24.7% had neurologic symptoms beyond VDS, 16.3% had neurologic exam findings, and 34.2% had either (P < 0.001, as compared to stroke). 43 patients (22.6%) lacked neurologic symptoms, exam findings, and stroke RFs; 40 had an adequate HINTS (head impulse, nystagmus, skew) exam. The most common imaging modality received by BPPV patients was plain CT Head (54.2%), followed by CT/CTA (43.7%), and MRI brain (26.3%). CT head was the initial imaging of choice in 44.7% and CT/CTA in 42.6%. CONCLUSIONS: Imaging utilization in BPPV patients presenting with VDS is high. The profile of patients with BPPV that received imaging was substantially more benign than that of stroke patients (a quarter had no neurologic symptoms, exam findings, or stroke RFs). The HINTS exam was underutilized, and computed tomography was heavily utilized despite well-established limitations in diagnosing posterior circulation strokes. This study highlights the need for increased training in the HINTS exam, narrowing of the scope for computed tomography, and a higher threshold for imaging patients with isolated VDS.

Effect of Epley, Semont Maneuvers and Brandt-Daroff Exercise on Quality of Life in Patients with Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo (PSCBPPV).

Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause in patients with vertigo (Pereira et al. in Braz J Otorhinolaryngol (Impr) 76(6):704-708, 2010; Dix and Hallpike in Ann Otol Rhinol Laryngol 6:987-1016, 1952). Posterior Semicircular Canal BPPV (PSCBPPV) has more incidence and prevalence then Lateral, and Anterior Semicircular Canal BPPV (Alghwiri et al. in Arch Phys Med Rehabil 93:1822-1831, 2012). Quality of life (QoL) is significantly impaired by vertigo (Sargent et al. in Otol Neurotol 22:205-209, 2001; World Health Organization in International classification of functioning, disability and health, World Health Organization, Geneva, 2001). To study the effect and compare Epley, Semont maneuvers and Brandt-Daroff Exercise on QoL in patients with PSCBPPV. 90 individuals with unilateral PSCBPPV were selected based on positive Dix-Hallpike test. 3 groups Epley, Semont, and Brandt-Daroff were formed and 30 individuals were selected in each group randomly. Dix-Hallpike test and Vestibular Activities and Participation (VAP) Scale based on International Classification of Functioning were administered before and after Epley, Semont maneuvers, and Brandt-Daroff Exercise to fulfill the aim. VAP Scale results revealed significant difference between pre and post treatment score in all 3 groups, suggestive of positive effect on QoL in patients with PSCBPPV. Improvements in VAP Score between 3 groups were compared and significant difference was observed. Dix-Hallpike test results revealed that 90, 73.33, and 50% patients improved in Epely, Semont, and Brandt-Daroff group respectively. Epely maneuver found to be the best choice and then Semont and Brandt-Daroff should be least preferred in treatment of patients with PSCBPPV.

Benign positional vertigo and endolymphatic hydrops: what is the connection?

BACKGROUND: Although benign paroxysmal positional vertigo and endolymphatic hydrops are considered to be distinct diagnoses, a minority of vertiginous patients exhibit features of both conditions. This coincidence has been reported previously in the literature, and is reviewed here in terms of possible aetiology. RESULTS AND CONCLUSION: A new hypothesis to account for both conditions is offered, implicating free-floating degenerating debris from the otolithic apparatus. It is postulated that the gelatinous/proteinaceous component may account for an osmotically induced hydrops, while the calcified fragments may induce positional vertigo.

Otoconia and otolithic membrane fragments within the posterior semicircular canal in benign paroxysmal positional vertigo.

OBJECTIVES/HYPOTHESIS: Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder with an incidence between 10.7 and 17.3 per 100,000 persons per year. The mechanism for BPPV has been postulated to involve displaced otoconia resulting in canalithiasis. Although particulate matter has been observed in the endolymph of affected patients undergoing posterior canal occlusion surgery, an otoconial origin for the disease is still questioned. STUDY DESIGN: In this study, particulate matter was extracted from the posterior semicircular canal of two patients and examined with scanning electron microscopy. METHODS: The samples were obtained from two patients intraoperatively during posterior semicircular canal occlusion. The particles were fixed, stored in ethanol, and chemically dehydrated. The samples were sputter coated and viewed under a scanning electron microscope. Digital images were obtained. RESULTS: Intact and degenerating otoconia with and without linking filaments were found attached to amorphous particulate matter. Many otoconia appeared to be partially embedded in a gel matrix, presumably that which encases and anchors the otoconia within the otolith membrane, whereas others stood alone with no attached filaments and matrix. The otoconia measured roughly 2 to 8 µm in length and displayed a uniform outer shape with a cylindrical bulbous body and a 3 + 3 rhombohedral plane at each end. CONCLUSIONS: These findings suggest that the source of the particulate matter in the semicircular canals of patients with BPPV is broken off fragments of the utricular otolithic membrane with attached and detached otoconia. LEVEL OF EVIDENCE: NA Laryngoscope, 127:709-714, 2017.

Clinical Characteristics of Horizontal Canal Benign Positional Vertigo: Analysis of 97 Cases

BACKGROUND: Horizontal canal benign positional vertigo (BPV) is characterized by direction-changing nystagmus beating to the lowermost ear (geotropic) or to the uppermost ear (apogeotropic) induced by head turning while the patient is lying down. The clinical features of horizontal canal BPV has rarely been studied in a large group of patients in Korea. METHODS: Ninety-seven patients with horizontal canal BPV were recruited from September 2000 to August 2003. The diagnosis of BPV was based on the typical nystagmus concurrent with vertigo elicited by positioning maneuvers. The type was divided into geotropic or apogeotropic. The demographic features, spontaneous nystagmus, positional nystagmus, results of head thrusting and head shaking, and nystagmus induced by lying down were analyzed. RESULTS: The patients included 68 (70.1%) women and 29 (29.9%) men. Mean age of the patients was 61.1 +/- 13.8 with no difference between women and men. They were divided into 54 (55.7%) geotropic and 43 (44.3%) apogeotropic types. The horizontal nystagmus was also provoked by Hallpike maneuver in 15 cases. Horizontal nystagmus was also induced by lying down from sitting to supine position in 7 patients; 3 apogeotropic and 4 geotropic. The nystagmus was ipsilesional in 2 of apogeotropic cases and contralesional in 2 of geotropic cases. CONCLUSIONS: In horizontal canal BPV, horizontal nystagmus may be induced by Hallpike maneuver or lying down as well as head turning in supine position. The direction of nystagmus induced by lying down may help deciding the side of the canal involved.

Multifaktorielles Schwindelgeschehen : Komplexes überwiegend psychogenes ("menièreiformes") Schwindelgeschehen, angestoßen durch einen benignen paroxysmalen Lagerungsschwindel.

We report about a patient with recurrent dizziness, looked upon for about 8 years as Menière's disease.He suffered from benign positional vertigo, which led to an additional psychogenic dizziness, connected to early live events.The different parts of complex dizziness, diagnosis and treatment will be described.

Clinical Characteristics of Benign Positional Vertigo

BACKGROUND: Benign positional vertigo (BPV) is characterized by episodic vertigo and nystagmus provoked by head motion. Though BPV is the most common cause of vertigo, systemic analysis of clinical features has been sparse. METHODS: We analyzed clinical features of 194 patients who had been diagnosed as having BPV in a dizziness clinic from September 2000 to December 2002. The diagnosis of BPV was based on the typical nystagmus concurrent with vertigo elicited by positioning maneuvers. The nystagmus was observed by using Frenzel glasses, or recorded with video- or electro-oculography. According to the semicircular canal involved, we classified BPV into posterior, horizontal, and anterior canal types. The horizontal canal type was subdivided into geotropic or apogeotropic. RESULTS: The patients included 149 women and 45 men. Mean age of the patients was 60.9 +/- 12.7 with no difference between women and men. Posterior (46.4%) and horizontal (40.7%) semicircular canals were most commonly involved. Most patients were idiopathic. Most patients (97.9%) were successfully treated with canalith repositioning procedure (CRP). CONCLUSIONS: BPV may involve each of the three semicircular canals. The involved canal can be identified by careful observation of the nystagmus induced by Hallpike maneuver or head turning in supine position. The horizontal canal is more commonly involved in BPV than previously known. High success rate of CRP is expected only when different method of CRP is applied to each patient depending on the canal involved.

Positional Downbeating Nystagmus : Tips from the Transitions

OBJECTIVE : To describe transitions of positional downbeating nystagmus (PDN) to or from the benign positional vertigo (BPV) involving the posterior (PC) or horizontal semicircular canal (HC). BACKGROUND : PDN occasionally occurs during Hallpike maneuver, and has been ascribed to BPV involving the anterior semicircular canal (AC-BPV). Method : Of the 168 patients diagnosed as having BPV in the Dizziness Clinic of Cheju National University Hospital over the past 2 years, three showed transitions of PDN which occurred during Hallpike maneuver. All the patients received full neurotological examinations. The diagnosis of BPV was based on the typical nystagmus concurrent with vertigo elicited by positional maneuvers. The nystagmus was observed by using Frenzel glasses. Nystagmus was also analyzed by using a video camera or video-oculography, as needed. RESULT : Two patients initially presented with torsional downbeating nystagmus during Hallpike maneuver. The torsional component beat toward the uppermost ear. Both patients later developed the PC or HC type of BPV in the uppermost ear. Another patient developed torsional upbeating nystagmus during Hallpike maneuver, consistent with right PC-BPV, following a motor vehicle accident. After Epley maneuver, the nystagmus was transformed into PDN which was observed during Hallpike maneuver to either side and during central head hanging. During Hallpike maneuver, the PDN was more prominent when the involved ear was lowermost. CONCLUSION : These transitions suggest that AC-BPV may involve the uppermost or lowermost ear during Hallpike maneuver. In patients with AC-BPV, the direction of torsional nystagmus may play a crucial role in deciding the affected ear during Hallpike maneuver.

A Case of Sudden Deafness with Simultaneous Ipsilateral Positional Vertigo

Although some cases of benign positional vertigo are associated with a chronic ipsilateral sensorineural hearing loss, an association with simultaneous ipsilateral sudden deafness is rare. We report a 53-year old woman with sudden deaf-ness with simultaneous positional vertigo in the same ear characterized by benign paroxysmal positional vertigo of pos-terior semicircular canal type. After a modified Epley particle-repositioning maneuver, the patient's vertigo was resolved. Clinical and neuro-otologic evaluations suggested that the lesion responsible for this patient was probably located within inner ear rather than within the vestibulocochlear nerve. (J Korean Neurol Assoc 19(4):410~412, 2001)