Inversion Test and Sitting-Up Oculomotor Patterns in Patients with Graviceptive Heavy Posterior Cupula - A Case Series.

A graviceptive heavy posterior cupula typically results from cupulolithiasis and clinically manifests as short vertigo spells when the head moves in the provocative position. Half-Hallpike test (HHT) in posterior cupulolithiasis (PSC-BPPV-cu) elicits an upbeating ipsitorsional nystagmus (UBITN), which lasts more than a minute as per the consensus criteria developed by the Barany Society. In the last decade, cases with canalolithiasis in the short arm of the posterior semicircular canal (PSC-BPPV-sa), wherein the otoconial debris falls on the utricular side of the posterior cupula on getting up from supine, rendering it heavy (graviceptive), have been reported. Such patients complain of sitting-up vertigo, associated with a constant disequilibrium, and anteroposterior truncal oscillations are recorded by ad hoc posturography in many of these patients. The oculomotor patterns generated in such patients during the HHT may be identical to those resulting from PSC-BPPV-cu. Rarely do the two conditions (PSC-BPPV-cu and PSC-BPPV-sa) coexist. Nine cases of graviceptive heavy cupula were diagnosed at our center over a period of 6 months from September 1, 2022, to March 31, 2023, with their characteristic diagnostic oculomotor patterns, distinguishing features, and management discussed. We propose a grading system for the inversion test during the HHT that reliably distinguishes PSC-BPPV-cu from PSC-BPPV-sa, as well as when the two conditions coexist.

Paroxysmal Positional Nystagmus in Acoustic Neuroma Patients.

The association between acoustic neuroma and positional vertigo with paroxysmal positional nystagmus is relatively rare, but, when present, it certainly represents a challenge for the otoneurologist. There are few reports in the literature on this particular issue, and some questions are still unanswered, particularly regarding the characteristics of positional nystagmus that may distinguish between a true benign paroxysmal vertigo and a positional nystagmus associated with the tumor. We present the videonystagmographic patterns of seven patients with acoustic tumor who had paroxysmal positional nystagmus and analyzed its features. A concomitant true benign paroxysmal positional vertigo may be present during the follow-up of a non-treated patient, as the paroxysmal positional vertigo may be the first symptom of the tumor, and it may show characteristics that are very similar to a posterior semicircular canal canalolithiasis or a horizontal canal "heavy or light cupula". The possible mechanisms are discussed.

"Sitting-up vertigo as an expression of posterior semicircular canal heavy cupula and posterior semicircular canal short arm canalolithiasis".

Background: Vestibular symptoms on sitting-up are frequent on patients seen by vestibular specialists. Recently, a benign paroxysmal positional vertigo (BPPV) variant which elicits vestibular symptoms with oculomotor evidence of posterior semicircular canal (P-SCC) cupula stimulation on sitting-up was described and named sitting-up vertigo BPPV. A periampullar restricted P-SCC canalolithiasis was proposed as a causal mechanism. Objective: To describe new mechanisms of action for the sitting-up vertigo BPPV variant. Methods: Eighteen patients with sitting-up vertigo BPPV were examined with a pre-established set of positional maneuvers and follow-up until they resolved their symptoms and clinical findings. Results: All patients showed up-beating torsional nystagmus (UBTN) and vestibular symptoms on coming up from either Dix-Hallpike (DHM) or straight head-hanging maneuver. Sixteen out of 18 patients presented a sustained UBTN with an ipsitorsional component to the tested side on half-Hallpike maneuver (HH). A slower persistent contratorsional down-beating nystagmus was found in eleven out 18 patients tested on nose down position (ND). Conclusions: Persistent direction changing positional nystagmus on HH and ND positions indicative of P-SCC heavy cupula was found in 11 patients. A sustained UBTN on HH with the absence of findings on ND, which is suggestive of the presence of P-SCC short arm canalolithiasis, was found on 5 patients. All patients were treated with canalith repositioning maneuvers without success, but they resolved their findings by means of Brandt-Daroff exercises. We propose P-SCC heavy cupula and P-SCC short arm canalolithiasis as two new putative mechanisms for the sitting-up vertigo BPPV variant.

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

Objective: This 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 method: The 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. Results: Thirty-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). Conclusion: Persistent 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.

Atypical Positional Vertigo: Definition, Causes, and Mechanisms.

Paroxysmal positional vertigo is a frequent cause for consultation. When approaching these patients, we try to differentiate central from peripheral causes, but sometimes we find manifestations that generate diagnostic doubts. In this review, we address atypical paroxysmal positional vertigo, reviewing the literature on the subject and giving a provisional definition of atypical positional vertigo as well as outlining its causes and pathophysiological mechanisms.

Recurrence in patients with benign paroxysmal positional vertigo of the lateral semicircular canal.

OBJECTIVES: There are 3 subtypes of lateral canal benign paroxysmal positional vertigo. Persistent geotropic positional nystagmus is due to a light cupula, heavy cupula produces apogeotropic positional nystagmus, and canalolithiasis accounts for transient geotropic positional nystagmus. The aims of this study were to determine the recurrence rate and to examine the number of times of recurrence in each of the 3 subtypes. METHODS: Subjects were patients with light cupula (n = 47), heavy cupula (n = 48), and canalolithiasis (n = 45). We investigated the number of times of recurrence and determined the subtypes of a recurrent vertigo attack over the period of 5 years. RESULTS: The subtype of a recurrent vertigo attack was not always the same as the subtype at the first visit. The recurrence rate of light cupula group was 72.3%, that of heavy cupula group was 20.8%, and that of canalolithiasis group was 28.9%. Some patients experienced recurrence more than once. The mean value and standard deviation of the number of times of recurrence in light cupula group was 2.5 ±â€¯1.3 times, that in heavy cupula group was 1.5 ±â€¯0.7 times, and that in canalolithiasis group was 1.5 ±â€¯0.7 times. CONCLUSIONS: The recurrence rate in patients with light cupula is much higher than that in patients with heavy cupula or canalolithiasis. The number of times of recurrence in patients with light cupula is greater than that in patients with heavy cupula or canalolithiasis.

Characteristics of positional nystagmus in patients with horizontal canal canalolithiasis or cupulopathy.

OBJECTIVES: Positional nystagmus can be related to various kinds of disorders. The current study aims to compare the direction-changing horizontal positional nystagmus (DCPN) characteristics in horizontal canal canalolithiasis (HC-canalolithiasis), heavy cupula of the horizontal canal (HC-Hcu), and light cupula of the horizontal canal (HC-Lcu), especially the temporal patterns of positional nystagmus in three disorders. METHODS: 52 patients (22 males, 30 females; mean age, 49.6 years) presenting with geotropic or apogeotropic DCPN were enrolled, and they were divided into HC-canalolithiasis, HC-Hcu, or HC-Lcu groups according their nystagmus characteristics. We compared their latency, time constant, peak slow-phase velocity (SPV), time to reach peak SPV intensity (Tpeak), and time to decay to half-peak intensity (T1/2peak). RESULTS: The time to reach peak SPV did not differ significantly between the HC-Hcu (23.1 ± 8.6 s) and HC-Lcu (24.4 ± 9.9 s) groups (p = 0.733), but was significantly longer than that of the HC-canalolithiasis group (5.4 ± 3.5 s; p ≤ 0.001). The peak intensity did not differ among the canalolithiasis (36.4 ± 20.6º/s), HC-Hcu (30.1 ± 23.6º/s), and HC-Lcu (21.4 ± 12.7º/s) groups (p = 0.133). The onset latency also had no statistical difference among three groups (p = 0.200). The nystagmus patterns of HC-Lcu and HC-Hcu groups were similar, including latency, peak SPV intensity, Tpeak, T1/2peak, and SPV in 20 s, 40 s, 60 s, 80 s. CONCLUSIONS: The nystagmus characteristics of HC-Hcu and HC-Lcu are similar, except for the fact that movement was in opposite directions, suggesting that HC-Hcu and HC-Lcu may result from a similar pathophysiological mechanism (cupulopathy) differing from that underlying canalolithiasis.

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.

Onset time of benign paroxysmal positional vertigo.

CONCLUSION: Benign paroxysmal positional vertigo (BPPV) is strongly related to sleep. This study proposes a micro-otoconia accumulation theory in which the pathological debris is an aggregate of micro-otoconia over a long time period, and which begins to slide by its own weight during sleep. OBJECTIVES: To examine the onset time of idiopathic BPPV and to investigate its etiology. METHOD: Patients (n = 351) were classified as posterior canalolithiasis (PC), horizontal canalolithiasis (HC), and horizontal heavy cupula (HHC) according to nystagmus findings. This study examined the medical records, and categorized the onset times into the following four groups; (1) during sleep, (2) at the time of rising, (3) morning, and (4) afternoon. RESULTS: PC (n = 135): In 33 patients, vertigo occurred during sleep, in 69 patients at rising, in 10 patients in the morning, and in 23 patients in the afternoon. HC (n = 87): In 38 patients, vertigo occurred during sleep, in 30 patients at rising, in eight patients in the morning, and in 11 patients in the afternoon. HHC (n = 129): In 27 patients, vertigo occurred during sleep, in 59 patients at rising, in 15 patients in the morning, and in 28 patients in the afternoon.

Neutral position of persistent direction-changing positional nystagmus.

The aim of this study was to measure the neutral position of direction-changing apogeotropic positional nystagmus (heavy cupula of the horizontal semicircular canal) and persistent direction-changing geotropic positional nystagmus (light cupula of the horizontal semicircular canal). We conducted a prospective case series study on 31 patients with heavy cupula (12 males, 19 females; mean age, 64.3 years) and 33 patients with light cupula (10 males, 23 females; mean age, 60.9 years). We measured the angle of the neutral position in patients with heavy cupula (θ 1) and that in patients with light cupula (θ 2) using a large protractor. The mean value and standard deviation of θ 1 was 31.6 ± 22.4°, minimum value was 5°, and maximum value was 89°. The mean value and standard deviation of θ 2 was 44.4 ± 20.5°, minimum value was 5°, and maximum value was 85°. θ 2 was significantly greater than θ 1 (p < 0.05). The neutral position varies widely. Some patients exhibit a great angle (more than 40°); therefore, examiners should make patients adopt a completely lateral position in the supine head roll test and should confirm the direction of nystagmus in order to avoid mistaking positional nystagmus for spontaneous nystagmus.

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.

Conversion between geotropic and apogeotropic persistent direction-changing positional nystagmus.

CONCLUSION: Clinical features in the course of conversion differed between patients with SSNHL and cupulopathy, which indicates that the pathophysiology of persistent geotropic or apogeotropic DCPN and the mechanism of the change in nystagmus direction may differ between the two groups. OBJECTIVE: The aim of this study is to investigate clinical characteristics of 10 patients with persistent DCPN who exhibited a conversion of nystagmus direction between geotropic and apogeotropic, and discuss possible mechanisms. METHODS: Using video-oculography, serial examinations of nystagmus in a head-roll test were performed. RESULTS: Of these 10 patients, five had sudden sensorineural hearing loss (SSNHL) and the remaining five had cupulopathy. In SSNHL, direction of nystagmus changed from geotropic to apogeotropic in three patients and from apogeotropic to geotropic in two patients. In cupulopathy, persistent apogeotropic DCPN always preceded persistent geotropic DCPN. The change in nystagmus direction occurred earlier in patients with cupulopathy (1 or 2 days after vertigo onset) than in patients with SSNHL (4-23 days after vertigo onset). While the null plane was consistently identified on one side, regardless of the nystagmus direction in cupulopathy, it was not always identified on the side of hearing loss in SSNHL.

A new method for evaluating lateral semicircular canal cupulopathy.

OBJECTIVES/HYPOTHESIS: Persistent direction-changing positional nystagmus (DCPN) during the supine head-roll test is a typical finding of cupulopathy. The aim of this study was to introduce a simple method of evaluating patients with cupulopathy (light cupula and heavy cupula), which is performed in a seated position, and investigate its diagnostic utility and use for lateralization. STUDY DESIGN: Retrospective case series. METHODS: Using video-oculography, nystagmus during head roll in the leaning and bending head positions while seated upright was evaluated in 26 patients with cupulopathy (five light cupula and 21 heavy cupula). The diagnosis of cupulopathy was confirmed with the supine head-roll test. RESULTS: Spontaneous nystagmus while seated upright was directed toward the ipsilesional side in heavy cupula and the contralesional side in light cupula. The first null point was identified when the head was slightly bent in the pitch plane in all 26 patients. Head rolling elicited a persistent geotropic DCPN in light cupula patients and persistent apogeotropic DCPN in heavy cupula patients during both leaning and bending head positions. In both light and heavy cupula, nystagmus disappeared when the head was turned slightly toward the affected side in both leaning (second null point) and bending (third null point) head positions. CONCLUSIONS: Cupulopathy and its affected side can be diagnosed by identifying the three null points while seated upright. LEVEL OF EVIDENCE: 4.

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.