Research in Vestibular Science

Reviews

Canal Conversion and Reentry of Otolith in Benign Paroxysmal Positional Vertigo: Jong Sei Kim, Minbum Kim; Res Vestib Sci. 2023;22(3):59-67. Published online September 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.3.59

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Abstract PDF: During the treatment process for benign paroxysmal positional vertigo (BPPV) using the canalith repositioning procedure, the otolith can inadvertently enter the semicircular canal instead of the utricle. Canal conversion refers to the situation where the otolith enters a different semicircular canal, while reentry occurs when the otolith returns to the same semicircular canal. The occurrence of a canal conversion can complicate the accurate diagnosis and treatment of BPPV, potentially leading to misdiagnosis and unsuccessful results in the canalith repositioning procedure. In this review, we aim to summarize the incidence, clinical features, and associated risk factors of canal conversion and reentries.

Light Cupula: Recent Updates: Dong-Han Lee, Chang-Hee Kim; Res Vestib Sci. 2023;22(2):23-33. Published online June 15, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.2.23

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Abstract PDF: Benign paroxysmal positional vertigo (BPPV) is the most common cause of positional vertigo and nystagmus. Direction-changing positional nystagmus (DCPN), which refers to the change in the direction of nystagmus with different head positions, is a well-known characteristic of horizontal semicircular canal BPPV. The supine head roll test is commonly used to diagnose horizontal canal BPPV. However, persistent geotropic DCPN observed during this test cannot be explained by conventional mechanisms of canalolithiasis or cupulolithiasis. The concept of a “light cupula” has been proposed to account for this unique nystagmus. In this review, we summarize the historical background, clinical features and diagnostic methods, presumed mechanisms, and treatment approaches of the light cupula phenomenon based on the available literatures up to date.

Treatment in Benign Paroxysmal Positional Vertigo: Factors that Affect Successful Treatment Outcome: Dae Bo Shim; Res Vestib Sci. 2023;22(1):1-6. Published online March 13, 2023; DOI: https://doi.org/10.21790/rvs.2023.22.1.1

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Abstract PDF: Benign paroxysmal positional vertigo (BPPV) is the most common etiology of benign vestibulopathy. Various treatments for BPPV have been developed, and appropriate treatments for each subtype of BPPV have been provided and used in accordance with clinical practice guidelines published by the American Academy of Otorhinolaryngology-Head and Neck Surgery in 2008 and 2017. Although many therapeutic maneuvers have been reported to show high success rates in the treatment of BPPV patients, some cases are not effective even by appropriate therapeutic maneuvers. This article reviews various factors affecting the successful treatment of BPPV patients.

Original Articles

The Head-Bending Test in Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo: Sol-lim Choi, Hyun-Sung Kim, Jae-Hwan Choi, Eun Hye Oh; Res Vestib Sci. 2022;21(4):99-103. Published online December 15, 2022; DOI: https://doi.org/10.21790/rvs.2022.21.4.99

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Abstract PDF: Objectives
This study aimed to investigate clinical significance of a head-bending test in benign paroxysmal positional vertigo (BPPV) involving the posterior semicircular canal (PC-BPPV).
Methods
We retrospectively recruited 256 patients with unilateral PC-BPPV between January 2016 and December 2021, and assessed the clinical characteristics of patients showing head-bending nystagmus (HBN).
Results
Of 256 patients, 138 (53.9%) showed HBN. Most patients (n=136, 98.6%) had downbeat nystagmus with (n=38) or without (n=98) torsional component. The remaining two patients had pure upbeat and torsional nystagmus, respectively. The torsional component was directed to the contralesional side in all. Between patients with and without HBN, there were no significant differences in clinical characteristics such as age, lateralization, types of BPPV (canalolithiasis or cupulolithiasis), and success rate of repositioning maneuver.
Conclusions
Head-bending test may be useful in predicting the diagnosis and lateralization of PC-BPPV.

Development of An Algorithm for Slippage-Induced Motion Artifacts Reduction in Video-Nystagmography: Yerin Lee, Young Joon Seo, Sejung Yang; Res Vestib Sci. 2022;21(4):104-110. Published online December 15, 2022; DOI: https://doi.org/10.21790/rvs.2022.21.4.104

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Abstract PDF: Objectives
The slippage of the video-nystagmography devices causes motion artifacts in the trajectory of the pupil and thus results in distortion in the nystagmus waveform. In this study, the moving average was proposed to reduce slippage-induced motion artifacts from the real-world data obtained in the field.
Methods
The dataset consists of an infrared video of positional tests performed on eight patients with a lateral semicircular canal benign paroxysmal positional vertigo. The trajectories of the pupil were obtained from the video with binarization, morphological operation, and elliptical fitting algorithm. The acquired data was observed and the section where the slippage occurred was labeled by an otolaryngologist. The moving average with windows of various lengths was calculated and subtracted from the original signal and evaluated to find the most adequate parameter to reduce the motion artifact.
Results
The period of nystagmus in the given data was found to be ranged from 0.01 to 4 seconds. The slippages that appeared in the data can be categorized into fast and slow slippages. The length, distance, and speed of trajectories in the slippage ranges were also measured to find the characteristics of the motion artifact in video-nystagmography data. The shape of the nystagmus waveform was preserved, and the motion artifacts were reduced in both types of slippages when the length of the window in moving average was set to 1 second.
Conclusions
The algorithm developed in this study is expected to minimize errors caused by slippage when developing a diagnostic algorithm that can assist clinicians.

Study on Platelet Indices in Benign Paroxysmal Positional Vertigo: Byeong Min Lee, Chae Dong Yim, Dong Gu Hur, Seong-Ki Ahn; Res Vestib Sci. 2021;20(4):141-146. Published online December 15, 2021; DOI: https://doi.org/10.21790/rvs.2021.20.4.141

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Abstract PDF: Objectives
Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness. Even though the etiology of BPPV has been widely studied, the exact mechanism remains still unclear. One of the possible factors explaining the pathophysiology of BPPV is ischemia of vestibule. In the present study, we have focused on the platelet indices including mean platelet volume (MPV), platelet distribution width (PDW), and platelet crit (PCT) to assess a risk of vestibule ischemia causing BPPV.
Methods
From January 2021 to March 2021, a retrospective review was performed on 39 patients diagnosed with BPPV through vestibular nystagmography. For each platelet indices, a comparative analysis was conducted between the patient group and control group.
Results
There were no significant differences when the platelet, MPV, PDW, and PCT values were compared between the study and control group. Rather, the control group showed higher PDW value than the study group.
Conclusions
Ischemia of vestibule is one of the well-known causes of BPPV, but the current study showed that BPPV cannot be explained by the vestibule ischemia itself. Further studies are needed to identify the potential of ischemia regarding BPPV by approaching with other methods with a large study group.

Which Is More Important for the Prognosis of Sudden Sensorineural Hearing Loss with Vertigo, Canal Paresis or Benign Paroxysmal Positional Vertigo?: Yong-Hwi An, Hyun Joon Shim; Res Vestib Sci. 2021;20(3):101-107. Published online September 15, 2021; DOI: https://doi.org/10.21790/rvs.2021.20.3.101

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Abstract PDF

Objectives
This study was performed to determine characteristics and the prognostic values in idiopathic sudden sensorineural hearing loss (SSNHL) with comorbid ipsilateral canal paresis (CP) and/or benign paroxysmal positional vertigo (BPPV).
Methods
Of the 338 patients with a diagnosis of idiopathic SSNHL, 29 patients (8.6%) with CP and 24 patients (7.1%) with BPPV were recruited and compared to 23 patients with SSNHL and vertigo but without CP or BPPV. The patients were evaluated for their initial hearing threshold, type of canal involved, response to repositioning maneuvers, and hearing outcome for 6 months.
Results
Patients with CP (+) BPPV (‒) showed lower pure-tone averages than those with CP (‒) BPPV (+) on initial and follow-up audiograms. The improvement in pure-tone averages was less in the CP (+) BPPV (‒) group than in the CP (‒) BPPV (+) group. The improvement in speech discrimination scores was less in the CP (+) BPPV (‒) group than in the CP (‒) BPPV (‒) group. BPPV most commonly involved the posterior canal (15 of 24, 62.5%), followed by the horizontal canal (13 of 24, 54.2%). Three of 24 patients (12.5%) had recurrences of BPPV.
Conclusions
CP is a more serious sign for hearing recovery than BPPV, although both CP and BPPV are negative prognostic indicators of auditory function in SSNHL. Concurrent CP and/or BPPV in SSNHL suggest combined damage to the vestibule and may indicate severe and widespread labyrinthine damage, leading to a poor prognosis.

Citations

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Re-fixation Saccade at Video-Head Impulse Test in Patients with Sudden Sensorineural Hearing Loss
Dong Hyuk Jang, Sun Seong Kang, Hyun Joon Shim, Yong-Hwi An
Research in Vestibular Science.2023; 22(2): 46. CrossRef

Review

Benign Paroxysmal Positional Vertigo: Diagnostic Criteria and Updated Practice Guideline in Diagnosis: Dae Bo Shim; Res Vestib Sci. 2020;19(4):111-119. Published online December 15, 2020; DOI: https://doi.org/10.21790/rvs.2020.19.4.111

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Abstract PDF: Benign paroxysmal positional vertigo (BPPV) is the most common cause of recurrent vertigo that is characterized by sudden onset of vertigo elicited by positional change. American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and American Academy of Neurology provided clinical practice guideline for BPPV in 2008. Since then, Bárány Society has published BPPV diagnostic criteria in 2015, and AAO-HNS has revised BPPV clinical practice guideline in 2017 to publish update version. This article reviewed recent diagnostic criteria for BPPV included in the International Classification of Vestibular Disorders of Bárány Society and updated practice guideline in the BPPV diagnosis presented by AAO-HNS.

Original Articles

The Periodic Fluctuation of Intra-Annual Distribution of Benign Paroxysmal Positional Vertigo and Meteorological Parameters: Chae Dong Yim, Ki Ju Cho, Hyun Jin Lee, Dong Gu Hur, Rock-Bum Kim, Seong-Ki Ahn; Res Vestib Sci. 2020;19(3):99-103. Published online September 15, 2020; DOI: https://doi.org/10.21790/rvs.2020.19.3.99

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Abstract PDF: Objectives
The influence of specific meteorological conditions, such as solar radiation quantity, duration of sunshine, and their covariation on the incidence of benign paroxysmal positional vertigo (BPPV) has been rarely investigated. Aiming at better predictions of the monthly variation of BPPV, we investigated variations in the monthly incidence of BPPV patients and meteorological parameters.
Methods
A total of 2,111 patients who had been diagnosed with BPPV at one institution were analyzed retrospectively. Monthly counts of BPPV patients were analyzed for incidence distributions throughout the 5 years. The relationship between intra-annual distribution of BPPV and meteorological parameters was compared by the time series analysis.
Results
The lowest monthly incidence of BPPV patients was found in September and the highest monthly incidence was found in December. Statistically, as a result of the time series analysis, a periodic fluctuation of both quantity of solar radiation (p=0.004) and percentage of sunshine duration (p=0.002) was identified, but a periodic fluctuation of both number of BPPV patients (p=0.316) and sunshine duration (p=0.057) was not identified.
Conclusions
Unlike previous studies, the results of time series analysis did not confirm that there is a periodic fluctuation in the incidence of BPPV patients. The incidence of BPPV may be more affected by other factors than by meteorological parameters.

Intravenous Zoledronic Acid in Elderly Patients with Benign Paroxysmal Positional Vertigo and Osteoporosis: Dong Won Kwack, Hyemi Lee, Dong Wook Kim; Res Vestib Sci. 2020;19(3):95-98. Published online September 15, 2020; DOI: https://doi.org/10.21790/rvs.2020.19.3.95

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Abstract PDF: Objectives
Benign paroxysmal positional vertigo (BPPV), a common cause of vertigo in the elderly, shares common pathogenic mechanisms with osteoporosis. We investigated the efficacy and safety of intravenous zoledronic acid in elderly patients with BPPV and osteoporosis.
Methods
We performed a 3-year observational study with elderly patients who were diagnosed with BPPV and osteoporosis. The recurrence of BPPV and changes in bone mineral densitometry (BMD) scores were evaluated one year after the administration of intravenous zoledronic acid.
Results
We enrolled 101 elderly patients with BPPV and 54 of them (53.5%) met the diagnostic criteria for osteoporosis. Intravenous zoledronic acid was administered in 51 patients. The recurrence of BPPV was observed in only two of 49 patients (4.1%) at 1 year’s follow-up. The mean lowest T-score of BMD improved from –3.23±0.51 to –3.05±0.58 (p=0.001).
Conclusions
Our study showed that the treatment of osteoporosis can be considered to prevent the recurrence of BPPV in the elderly. Further placebo-controlled studies are needed to estimate accurately the efficacy of zoledronic acid in the prevention of recurrence of BPPV in the elderly.

Influence of Otoliths on the Vestibulo-Ocular Reflex in Horizontal Canal Benign Paroxysmal Positional Vertigo: Hee Soo Yoon, Jae Yeong Jeong, Jae Ho Chung, Ha Young Byun, Chul Won Park, Seung Hwan Lee; Res Vestib Sci. 2020;19(2):49-54. Published online June 15, 2020; DOI: https://doi.org/10.21790/rvs.2020.19.2.49

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Abstract PDF: Objectives
The aim of the study was to evaluate the possible alteration of the vestibulo-ocular reflex (VOR) in patients with horizontal canal benign paroxysmal positional vertigo (h-BPPV) using the video head impulse test (vHIT).
Methods
This was a prospective case-control study of BPPV patients. We includeed 133 patients with h-BPPV who underwent the vHIT prior to the positioning test. The control group consisted of 76 normal subjects who also underwent the vHIT. The vHIT parameters of gain and asymmetry were assessed, and clinical parameters such as treatment duration, number of canalith reposition maneuvers executed and recurrence rates were evaluated. The VOR and clinical parameters were compared between the h-BPPV and control group. The VOR parameters of h-BPPV canalolithiasis were also compared with those of cupulolithiasis.
Results
The mean age of the patients was 56.5 years and the male to female ratio was 1:2.02. Of the patients, 75 were diagnosed as having the canalolithiasis type of h-BPPV, while the other 58 had the cupulolithiasis type. The mean vHIT gains of the ipsi-lesional horizontal canal plane were 1.13 and 1.15 in the h-BPPV and control group, respectively (p=0.564). However, the asymmetry of the VOR was significantly higher in the h-BPPV than the control group (p=0.013), while the gains and asymmetries of the vHIT in the canalolith and cupulolith types were not significantly different (p=0.454, p=0.826).
Conclusions
The asymmetry of VOR is significantly elevated in the cupulolith type of hBPPV.

Can Cupulolithiasis Affect the Time Constant or Gain of the Velocity Step Test?: Min Tae Kim, Ji Eun Choi, Min Young Lee, Jae Yun Jung; Res Vestib Sci. 2019;18(4):98-102. Published online December 15, 2019; DOI: https://doi.org/10.21790/rvs.2019.18.4.98

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Abstract PDF

Objectives
The nystagmus evoked by an angular velocity step is influenced by the cupula dynamics and the status of velocity storage mechanisms. This study questioned whether the cupulolithiasis of horizontal canal benign paroxysmal positional vertigo (HC-BPPV) affects the time constant or gain of the velocity step test.
Methods
We performed a retrospective study of 30 patients who diagnosed with HC-BPPV and performed rotary chair test at Dankook University Hospital from June 2010 to May 2017. All patients had normal vestibular function on the sinusoidal harmonic acceleration test. According to the direction of nystagmus on the head roll test, we further divided the patients into “geotrophic” (canalolithiasis) and “apogeotrophic” (cupulolithiasis) groups. We compared the time constant (Tc), gain, and directional preponderance (DP) between the 2 groups. We also compared the time constant and gain between lesion side of BPPV and normal side in each group.
Results
In the supine head roll, geotrophic nystagmus observed in 14 patients and apogeotrophic nystagmus observed in 16 patients. When parameters of the velocity step test compared according to lesion side of BPPV (per-rotary of lesion side, postrotary of lesion side, per-rotary of normal side, and postrotary of normal side), there were no significant differences in Tc, gain, and DP between the 2 groups. There were also no significant differences in Tc and gain between lesion side and normal side in each group.
Conclusions
We assumed that cupulolithiasis of HC-BPPV could affect the cupular deflection evoked by an angular velocity step, but there were no significant differences in Tc and gain between patients with cupulolithiasis and canalolithiasis.

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Influence of Otoliths on the Vestibulo-Ocular Reflex in Horizontal Canal Benign Paroxysmal Positional Vertigo
Hee Soo Yoon, Jae Yeong Jeong, Jae Ho Chung, Ha Young Byun, Chul Won Park, Seung Hwan Lee
Research in Vestibular Science.2020; 19(2): 49. CrossRef

Case Reports

Arnold-Chiari Type 1 Malformation Mimicking Benign Paroxysmal Positional Vertigo: Young Chul Kim, Chae Dong Yim, Hyun Jin Lee, Dong Gu Hur, Seong Ki Ahn; Res Vestib Sci. 2019;18(3):87-90. Published online September 15, 2019; DOI: https://doi.org/10.21790/rvs.2019.18.3.87

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Abstract PDF: Arnold-Chiari malformation type 1 is a congenital disease characterized by herniation of the cerebellar tonsils through the foramen magnum. Most common clinical symptom is pain, including occipital headache and neck pain, upper limb pain exacerbated by physical activity or valsalva maneuvers. Various otoneurological manifestations also occur in patients with the disease, which has usually associated with dizziness, vomiting, dysphagia, poor hand coordination, unsteady gait, numbness. Patients with Arnold-Chiari malformation may develop vertigo after spending some time with their head inclined on their trunk. Positional and down-beating nystagmus are common forms of nystagmus in them. We experienced a 12-year-old female who presented complaining of vertigo related to changes in head position which was initially misdiagnosed as a benign paroxysmal positional vertigo.

Benign Paroxysmal Positional Vertigo after Yoga Practice: Soo-Hyun Soh, Hak Seung Lee; Res Vestib Sci. 2019;18(3):78-82. Published online September 15, 2019; DOI: https://doi.org/10.21790/rvs.2019.18.3.78

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Abstract PDF: A 57-year-old woman presented with sudden onset of whirling vertigo associated with nausea and vomiting. The neurological examination showed left-beating horizontal nystagmus on the lying-down test and right-beating horizontal nystagmus on the head bending test. Geotropic direction-changing horizontal nystagmus was demonstrated on both sides during the supine roll test. Benign paroxysmal positional vertigo (BPPV) was the most common vestibular disorder in patients after head trauma. The authors experienced a case of right horizontal canal BPPV occurred after a yoga practice, thereby we report the case with a review of the related literatures.

Original Article

Outcome of Canalith Repositioning Procedure in Patients with Persistent and Transient Geotropic Direction-Changing Positional Nystagmus: Short-term Follow-up Evaluation: Seung Sik Jeon, Sung Won Li, Sung Kyun Kim, Yong Bok Kim, Il-Seok Park, Seok Min Hong; Res Vestib Sci. 2018;17(3):109-115. Published online September 18, 2018; DOI: https://doi.org/10.21790/rvs.2018.17.3.109

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Abstract PDF: Objectives
Patients, who showed persistent geotropic-direction changing positional nystagmus (p-DCPN) tend to have different clinical manifestations from those who showed transient geotropic DCPN (t-DCPN). We investigated the clinical characteristics between p-DCPN and t-DCPN patients, and its recovery rate after canalith repositioning procedure (CRP).
Methods
Based on the duration of nystagmus, 117 geotropic DCPN patients were classified to 2 groups, p-DCPN and t-DCPN. Barbeque maneuver had been introduced towards the opposite direction of null plane for the p-DCPN patients, and to the opposite direction of stronger nystagmus for the t-DCPN patients.
Results
Seventy-four patients showed t-DCPN and 43 patients were classified to the p-DCPN cases. No p-DCPN patient showed prompt improvement after the 1st canalolith reposition therapy. Among the t-DCPN patients, 18 canal switch cases were found , but, there was no canal switch cases found among the p-DCPN The CRP has showed less effective for the p-DCPN patients than the t-DCPN patients (after the 1st CRP, 37 in 74 improved, p＜0.001).
Conclusions
Due to its distinguishing clinical manifestation, p-DCPN may have different pathogenesis and clinical mechanisms from t-DCPN. And for the p-DCPN patients, the CRP seems not an efficient treatment compared to the t-DCPN patients. Further study with larger number of enrolled subjects is necessary.

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