Search Results (12)

Background: Positional torsional downbeating nystagmus elicited during diagnostic maneuvers for posterior semicircular canal benign paroxysmal positional vertigo (PSC-BPPV) may indicate either ipsilateral apogeotropic PSC-BPPV or contralateral anterior canal BPPV, making differential diagnosis challenging. This retrospective study evaluated whether ipsilateral 100 Hz mastoid vibration could facilitate conversion to a geotropic nystagmus pattern, thereby supporting both diagnosis and treatment. Materials and Methods: Ten patients with apogeotropic PSC-BPPV underwent standard diagnostic and therapeutic maneuvers combined with ipsilateral 100 Hz mastoid vibration. The primary outcome was the rate of nystagmus geotropization. Secondary outcomes included the number of repositioning maneuvers required to achieve complete symptom resolution. Outcomes were compared with those of two control groups: one consisting of patients with apogeotropic PSC-BPPV treated without mastoid vibration and another consisting of patients with typical PSC-BPPV treated using standard repositioning maneuvers alone. Results: Mastoid vibration induced geotropization in 7 out of 10 patients (70%). The mean number of liberatory maneuvers required for symptom resolution was lower in vibration-responsive patients than in vibration-non-responsive patients (1.7 ± 0.49 vs. 3.0 ± 1.41;). Compared with patients with apogeotropic PSC-BPPV treated without mastoid vibration, vibration-responsive patients required significantly fewer maneuvers (2.1 ± 0.87 vs. 2.9 ± 0.74; p = 0.036). No significant difference was observed when compared with patients with typical PSC-BPPV (2.1 ± 0.87 vs. 2.1 ± 0.52; p = 0.82). Conclusions: Mastoid vibration may represent a useful adjunctive tool in the management of apogeotropic PSC-BPPV by facilitating conversion to the typical geotropic pattern. This conversion may provide useful diagnostic information, and potentially reduce the number of repositioning maneuvers required to achieve symptom resolution. Full article

Background: Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder and most frequently involves the posterior semicircular canal (PSC). Atypical apogeotropic variants of PSC-BPPV may present with pure down-beating positional nystagmus, mimicking contralateral anterior semicircular canal involvement and resulting in diagnostic and therapeutic uncertainty. Objective: To assess the effectiveness of the Bascule/Pendular maneuver in managing patients with pure down-beating positional nystagmus and suspected apogeotropic PSC-BPPV. Methods: A total of 178 patients presenting with pure down-beating positional nystagmus without a torsional component were evaluated using a standardized diagnostic protocol under video-Frenzel goggle monitoring. All patients underwent the Bascule/Pendular maneuver, a modification of the classical Semont maneuver designed to mobilize otoconial debris along the vertical canal planes (Left Anterior–Right Posterior and Right Anterior–Left Posterior), regardless of precise lateralization. Conversion of nystagmus from the apogeotropic to the geotropic variant was considered the primary outcome. Results: The maneuver was well tolerated, with no procedural interruptions or complications. Immediate conversion to the geotropic variant was achieved in 86 patients (48.3%) after a single maneuver. In the remaining patients, successful conversion was obtained after additional maneuvers, most commonly following a second application on the contralateral plane. Once geotropization was achieved, all patients were successfully treated using a standard posterior canal repositioning maneuver. Conclusions: The Bascule/Pendular maneuver is a practical and effective approach for patients presenting with pure down-beating positional nystagmus and suspected apogeotropic PSC-BPPV. By facilitating conversion to the geotropic form, it allows prompt treatment with conventional repositioning maneuvers and may represent a useful first-line strategy in atypical BPPV presentations. Full article

Introduction: The aim of this study was to determine the position of otoconial debris in lateral ampullar or non-ampullar canalolithiasis, based on two parameters: (1) the direction of the nystagmus appearing when the patient lies down, if present, and (2) the positional nystagmus evoked by the supine roll test. Methods: Theoretical results were compared with a population of 170 patients observed over the past ten years for horizontal canal benign paroxysmal positional vertigo (HC-BPPV). The series included 141 geotropic and 29 apogeotropic cases. Results: Among the geotropic forms, 80 showed no supine nystagmus (Geotropic Nystagmus with no supine nystagmus, GT0) (56.7%), 51 had supine nystagmus directed toward the healthy side (Geotropic Nystagmus with supine nystagmus congruent, direct toward the healthy side, GT+) (36.2%), and 10 toward the affected side (Geotropic Nystagmus with supine nystagmus incongruent direct to the affected side, GT−) (7.1%). In the apogeotropic group, 10 showed no supine nystagmus (Apogeotropic nystagmus with no supine nystagmus, AGT0) (34.6%), 16 had nystagmus toward the affected side (Apogeotropic Nystagmus with supine nystagmus congruent, direct toward the affected side, AGT+) (55.2%), and 1 toward the healthy side (Apogeotropic Nystagmus with supine nystagmus Incongruent, direct toward the healthy side, AGT−) (3.4%). Two cases presented monopositional apogeotropic nystagmus (mAGT), consistent with a “sieve-type canal jam” (6.8%). Overall, 90 out of 170 patients (52.9%) showed no nystagmus in the supine position, with a statistically significant difference between variants (p = 0.0474, Yates correction). Conclusions: The comparison between lying-down nystagmus and positional nystagmus, assessed through the Supine Roll Test as the leading diagnostic maneuver for horizontal canal involvement, may help identify the initial location of debris within the lateral semicircular canal and guide the appropriate liberatory maneuver, while the effectiveness and side of the maneuver allow the distinction between canal-side and utricular-side jams. Full article

Background: Posterior canal benign paroxysmal positional vertigo (PSC-BPPV) is the most frequently encountered vestibular disorder in otoneurological clinical practice. However, diagnosis may be challenging in the presence of less common variants, which are characterised by atypical nystagmus patterns and may complicate clinical assessment. Methods: This study analysed a cohort of 295 patients diagnosed with PSC-BPPV and treated between January and August 2025 at the Audiology and Phoniatrics Unit of San Pio Hospital, Benevento. Of these, 25 patients presented with less common PSC-BPPV variants, namely the apogeotropic variant, the Scocco variant, and the Yetiser variant. Clinical features, therapeutic manoeuvres performed, time to symptom resolution, and associated comorbidities were evaluated. All patients were treated exclusively using the Epley manoeuvre. This observational study describes our experience in the diagnosis and management of these rare PSC-BPPV variants, with the aim of expanding the currently available evidence. Results: The Scocco variant was the only less common form of PSC-BPPV that required a statistically significantly greater number of liberatory manoeuvres when compared with classic PSC-BPPV (p < 0.05). No statistically significant differences were observed for the remaining variants with regard to treatment response or time to symptom resolution. Conclusions: Less common variants of PSC-BPPV represent both diagnostic and therapeutic challenges due to their atypical nystagmus patterns. Our findings indicate that the Scocco variant may be more resistant to standard liberatory treatment. In addition, this study reports auxiliary diagnostic and clinical tools which, in our experience, facilitated patient management. Full article

Background and Clinical Significance: Benign paroxysmal positional vertigo (BPPV) most commonly involves the posterior semicircular canal (PSC), whereas anterior semicircular canal BPPV (ASC-BPPV) is rare, accounting for only 1–3% of cases. Most ASC-BPPV cases respond well to particle repositioning maneuvers (PRMs), with refractory presentations being exceptional and diagnostically challenging, particularly when differential diagnoses such as apogeotropic posterior semicircular canal BPPV (PSC-BPPV) or central causes must be excluded. Case Presentation: A 43-year-old woman presented with vertigo triggered by head extension and rolling in bed. Initial neurological and otoneurological examinations were unremarkable. During the left Dix–Hallpike maneuver, a vertical down-beating nystagmus with subtle leftward torsion appeared after a 5 s latency and lasted 15 s. The supine head-hanging maneuver provoked a stronger and longer 30 s response, while the right Dix–Hallpike was negative. Despite repeated PRMs, including Yacovino (Deep Head-hanging), reverse Epley, Epley, and modified Semont maneuvers, the patient remained symptomatic over three years. Intermittently, conversion to PSC-BPPV was suspected, and temporary resolution was achieved after left-sided Epley and Semont maneuvers, but recurrence followed. Treatment with a mechanical rotational chair (TRV) initially resolved symptoms, but vertigo recurred several months later following two syncopal episodes with minor trauma. Extensive neurological evaluation, including MRI, CT, EEG, and vascular ultrasound, excluded central causes. Conclusions: This case illustrates the diagnostic and therapeutic difficulties posed by refractory ASC-BPPV, particularly in differentiating it from apogeotropic PSC-BPPV and central etiologies. It underscores the importance of latency, torsional characteristics, and supine head-hanging testing in diagnosis and demonstrates the potential role of mechanical rotational chairs in management. Personalized approaches incorporating anatomical imaging and maneuver adaptation are essential in such complex cases. Full article

Dr. Epley has been instrumental in defining the mechanisms and treatment of BPPV variants, including those of the horizontal canals. Cupulolithiasis is a horizontal canal BPPV variant usually defined as direction-changing apogeotropic nystagmus. In recent years, the favored cupulolithiasis mechanism of otoconia adhering persistently to the cupula has been called into question. Epley was the first to propose mechanistic theories which better match the most recent evidence. From the beginning, he has demonstrated mastery over the semicircular canal pathology and otoconial mechanics. Full article

Objectives: Even though BPPV is one of the most common causes of vertigo, it is often underdiagnosed and omitted in the diagnosis of patients reporting vertigo. The aim of the study was to establish a diagnostic pattern useful in patients admitted due to vertigo, based on the most common clinical characteristics of patients suffered from posterior canal BPPV (PC-BPPV), horizontal canal BPPV with geotropic (HCG-BPPV) and apogeotropic nystagmus (HCA-BPPV). Methods: The analysis covered the results obtained in 105 patients with a positive result of the Dix-Hallpike maneuver or the supine roll test. The patients were divided into 3 groups based on the BPPV type: gr.1:PC-BPPV (60%); gr.2: HCG-BPPV (27%); gr.3: HCA-BPPV (13%). Patients before the diagnostic maneuvers filled the questionnaire concerning their symptoms and previous diseases. Results: Almost all patients had vertigo during turning over in bed and the character of the symptoms was paroxysmal. The answers to questions about the type of head movement evoked vertigo and how long vertigo lasted were differentiating. The percentages of correct diagnosis speculated by the combined answers were 69.6% in PC-BPPV, 61.8% in HCG-BPPV, and 80% in HCA-BPPV. Conclusions: Basing on those observations there is presented the diagnostic schedule which could be useful in dizziness examination. The above results indicate that a properly collected interview with the patient allows for a high percentage of accurate diagnosis. Full article

Benign paroxysmal positional vertigo (BPPV) is one of the most common disorders that causes dizziness. The incidence of horizontal semicircular canal (HSC) BPPV ranges from 5% to 40.5% of the total number of BPPV cases diagnosed. Several studies have focused on establishing methods to treat BPPV caused by the apogeotropic variant of the HSC, namely, the Appiani maneuver (App). In 2016, a new maneuver was proposed: the Zuma e Maia maneuver (ZeM), based on inertia and gravity. The aim of this study is to analyze the efficacy of App versus ZeM in the resolution of episodes of BPPV produced by an affectation of the horizontal semicircular canal with apogeotropic nystagmus (Apo-HSC). A retrospective, quasi-experimental study was conducted. Patients attended in office (November 2014–February 2019) at a third-level hospital and underwent a vestibular otoneurology assessment. Those who were diagnosed with Apo-HSC, treated with App or ZeM, were included. To consider the efficacy of the maneuvers, the presence of symptoms and/or nystagmus at the first follow up was studied. Patients classified as “A” were those with no symptoms, no nystagmus; “A/N+”: no symptoms, nystagmus present during supine roll test; “S”: symptoms present. Previous history of BPPV and/or otic pathology and calcium levels were also compiled. From the 54 patients included, 74% were women. The average age was 69. Mean follow-up: 52.51 days. In those patients without previous history of BPPV (n = 35), the probability of being group “A” was 63% and 56% (p = 0.687) when treated with App and ZeM, respectively, while being “A/N+” was 79% and 87% for App and ZeM (p = 0.508). Of the 19 patients who had previous history of BPPV, 13% and 64% were group “A” when treated with App and ZeM (p = 0.043), and 25% and 82% were “A/N+” after App and ZeM, respectively (p = 0.021). In conclusion, for HSC cupulolithiasis, ZeM is more effective than App in those cases in which there is a history of previous episodes of BPPV (“A”: 64% (p = 0.043); “A/N+”: 82% (p = 0.021)). Full article

There have been no reports regarding nystagmus observed immediately after the end of an acute vertiginous attack in patients with Meniere’s disease. The aim of this study was to demonstrate positional direction-changing nystagmus in patients with Meniere’s disease, and to discuss the mechanism that underlies this nystagmus. Video-nystagmography was recorded in two patients with definite Meniere’s disease, who showed positional direction-changing nystagmus during the period immediately after a vertigo attack. In one patient, video-nystagmographic recording was conducted 5 h after an episode of vertigo attack, and it showed very weak, persistent positional geotropic direction-changing nystagmus. In the other patient, video-nystagmographic recording was conducted 23 h after an episode of vertigo attack, and it showed very weak, persistent positional apogeotropic direction-changing nystagmus. Our patients exhibited very weak, persistent positional direction-changing nystagmus, which was geotropic in one and apogeotropic in the other. This type of positional nystagmus has been reported in other inner ear disorders and it cannot be clearly explained by typical benign paroxysmal positional vertigo. The change in chemical composition and/or electrolyte concentration of the inner ear fluid, although still unclear, may underlie the production of this characteristic nystagmus in these patients. Full article

The aim of this study was to assess the prevalence and analyze clinical parameters of benign positional paroxysmal vertigo (BPPV) in a pediatric age. A cohort of 423 children under the age of 15 (median age 11. interquartile range 9–13) was submitted to vestibular assessment for balance disorders. Dix-Hallpike and Roll-Supine tests were performed to look for positioning nystagmus using video-infrared goggles. BPPV was found in 43 of 423 children evaluated for balance disorders (10.2%). There were 28 females (65.1%) and 15 (34.9%) males. The posterior canal was involved in 79% of cases and the horizontal canal in 21% of cases. No apogeotropic bilateral or anterior canal form were seen. Thus, BPPV is not an infrequent type of vertigo in children and must be evaluated as soon as possible in order to plan the most appropriate maneuver and restore daily activities as soon as possible, avoiding anxiety and fear. Full article

The apogeotropic variant of horizontal semicircular canal benign paroxysmal positional vertigo (HC-BPPV) is attributed to free floating particles in the anterior arm of the lateral semicircular canal – particles attached to the cupula facing the canal or particles attached to the cupula facing the utricle. Zuma e Maia described a new treatment for both canalithiasis of the anterior arm of the horizontal semicircular canal (HC) and cupulolithiasis of the HC. Seventeen patients with apogeotropic HC-BPPV were enrolled and treated with Zuma’s Maneuver. During the repositioning of the particles to the utricule, we observed the direction of the nystagmus evoked in each step of this maneuver in order to know where the otoliths were probably located. Eight patients were diagnosed with canalithiasis of the anterior arm, six patients with cupulolithiasis with the particles facing the canal and three patients with cupulolithiasis with the particles facing the utricle. Our data suggest that we can assume where the otoliths are probably located by observing the pattern of the nystagmus evoked in each step of the Zuma’s Maneuver in patients with apogeotropic HC-BPPV. Full article

We lately reported the cases of patients complaining positional vertigo whose nystagmic pattern was that of a peripheral torsional vertical positional down beating nystagmus originating from a lithiasis of the non-ampullary arm of the posterior semicircular canal (PSC). We considered this particular pathological picture the apogeotropic variant of PSC benign paroxysmal positional vertigo (BPPV). Since the description of the pilot cases we observed more than 150 patients showing the same clinical sign and course of symptoms. In this paper we describe, in detail, both nystagmus of apogeotropic PSC BPPV (A-PSC BPPV) and symptoms reported by patients trying to give a reasonable explanation for these clinical features. Moreover we developed two specific physical therapies directed to cure A-PSC BPPV. Preliminary results of these techniques are related. Full article