Upright BPPV Protocol: Feasibility of a New Diagnostic Paradigm for Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo Compared to Standard Diagnostic Maneuvers

Abstract

Background: The diagnosis of benign paroxysmal positional vertigo (BPPV) involving the lateral semicircular canal (LSC) is traditionally entrusted to the supine head roll test, also known as supine head yaw test (SHYT), which usually allows identification of the pathologic side and BPPV form (geotropic vs. apogeotropic). Nevertheless, SHYT may not always allow easy detection of the affected canal, resulting in similar responses on both sides and intense autonomic symptoms in patients with recent onset of vertigo. The newly introduced upright head roll test (UHRT) represents a diagnostic maneuver for LSC-BPPV, supplementing the already-known head pitch test (HPT) in the sitting position. The combination of these two tests should enable clinicians to determine the precise location of debris within LSC, avoiding disturbing symptoms related to supine positionings. Therefore, we proposed the upright BPPV protocol (UBP), a test battery exclusively performed in the upright position, including the evaluation of pseudo-spontaneous nystagmus (PSN), HPT and UHRT. The purpose of this multicenter study is to determine the feasibility of UBP in the diagnosis of LSC-BPPV.Methods: We retrospectively reviewed the clinical data of 134 consecutive patients diagnosed with LSC-BPPV. All of them received both UBP and the complete diagnostic protocol (CDP), including the evaluation of PSN and data resulting from HPT, UHRT, seated-supine positioning test (SSPT), and SHYT.Results: A correct diagnosis for LSC-BPPV was achieved in 95.5% of cases using exclusively the UBP, with a highly significant concordance with the CDP (p < 0.000, Cohen's kappa = 0.94), regardless of the time elapsed from symptom onset to diagnosis. The concordance between UBP and CDP was not impaired even when cases in which HPT and/or UHRT provided incomplete results were included (p < 0.000). Correct diagnosis using the supine diagnostic protocol (SDP, including SSPT + SHYT) or the sole SHYT was achieved in 85.1% of cases, with similar statistical concordance (p < 0.000) and weaker strength of relationship (Cohen's kappa = 0.80).Conclusion: UBP allows correct diagnosis in LSC-BPPV from the sitting position in most cases, sparing the patient supine positionings and related symptoms. UBP could also allow clinicians to proceed directly with repositioning maneuvers from the upright position.

The horizontal and vertical components of nystagmus evoked by the supine roll test in horizontal semicircular canal canalolithiasis

“…In HSC-Can, gravity induces the rolling of the otoconia from the posterior arm of the HSC toward the ampulla on the affected side, driving the endolymph to the ampulla, while the otoconia roll to the canal from the ampulla driving the endolymph away from the ampulla ( Martellucci et al, 2020 ; Zhang et al, 2020 ). This results in a single stimulus to the HSC without involving the anterior and posterior semicircular canals.…”

Case Report: Bow Hunter Syndrome—One Reason to Add Non-gravity Dependent Positional Nystagmus Testing to Your Clinical Neuro-Otologic Exam

“…Thus, our case highlights the importance of associating a patient's symptoms and history with the results of positional testing for nystagmus in both gravity and non-gravity dependent positions. Clinicians do not typically perform positional testing for nystagmus with the patients head in upright, though recent literature suggests using an upright head position to test for nystagmus can be useful to discern peripheral vestibular from vascular causes of vertigo (19)(20)(21).…”

Recovery of Regular Daily Physical Activities Prevents Residual Dizziness after Canalith Repositioning Procedures

“…Both spontaneous and gaze-evoked nystagmus with and without fixation were checked using infrared video-Frenzel goggles. According to our nystagmus-based approach, the patients underwent diagnostic positioning tests for BPPV according to the minimum stimulus strategy [ 25 , 26 ]. PSC-BPPV was diagnosed if the Dix–Hallpike test evoked typical paroxysmal nystagmus (up-beating and torsional nystagmus with the upper pole of the eyes beating toward the undermost ear, lasting < 1 min).…”