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Persistent Down-Beating Torsional Positional Nystagmus: Posterior Semicircular Canal Light Cupula?

ABSTRACT: A 16-year-old boy with rotatory positional vertigo and nausea, particularly when lying down, visited our clinic. Initially, we observed vertical/torsional (downward/leftward) nystagmus in the supine position, and it did not diminish. In the sitting position, nystagmus was not provoked. Neurological examinations were normal. We speculated that persistent torsional down-beating nystagmus was caused by the light cupula of the posterior semicircular canal. This case provides novel insights into the light cupula pathophysiology.

SUBMITTER: Ichimura A

PROVIDER: S-EPMC5030422 | biostudies-literature | 2016

REPOSITORIES: biostudies-literature

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Persistent Down-Beating Torsional Positional Nystagmus: Posterior Semicircular Canal Light Cupula?

Ichimura Akihide A Otsuka Koji K

Case reports in otolaryngology 20160907

A 16-year-old boy with rotatory positional vertigo and nausea, particularly when lying down, visited our clinic. Initially, we observed vertical/torsional (downward/leftward) nystagmus in the supine position, and it did not diminish. In the sitting position, nystagmus was not provoked. Neurological examinations were normal. We speculated that persistent torsional down-beating nystagmus was caused by the light cupula of the posterior semicircular canal. This case provides novel insights into the ...[more]

PMID: 27668113

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

Project description:BackgroundVestibular 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.ObjectiveTo describe new mechanisms of action for the sitting-up vertigo BPPV variant.MethodsEighteen 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.ResultsAll 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).ConclusionsPersistent 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.

| S-EPMC9349016 | biostudies-literature

Persistent Upbeat Positional Nystagmus in a Patient with Bilateral Posterior Canal Benign Paroxysmal Positional Vertigo.

Project description:Here, we report a patient with persistent positional upbeat nystagmus in a straight supine position with no evident abnormal central nervous system findings. A 43-year-old woman with rotatory positional vertigo and nausea visited our clinic 7 days after the onset. Initially, we observed persistent upbeat nystagmus in straight supine position with a latency of 2 s during the supine head roll test. However, an upbeat nystagmus disappeared on turning from straight to the left ear-down supine position, and while turning from the left to right ear-down position, an induced slight torsional nystagmus towards the right for >22 s was observed. In the Dix-Hallpike test, the left head-hanging position provoked torsional nystagmus towards the right for 50 s. In prone seated position, downbeat nystagmus with torsional component towards the left was observed for 45 s. Neurological examination and brain computed tomography revealed no abnormal findings. We speculated that persistent positional upbeat nystagmus in this patient was the result of canalolithiasis of benign paroxysmal positional vertigo of bilateral posterior semicircular canals.

| S-EPMC6458853 | biostudies-literature

Light cupula: the pathophysiological basis of persistent geotropic positional nystagmus.

Project description:To clarify the pathophysiological basis of persistent geotropic positional nystagmus (PGN) in patients with the horizontal canal type of benign paroxysmal positional vertigo (H-BPPV), the time constant (TC) of nystagmus and the relationship between its slow phase eye velocity (SPV) and the angle of head rotation in supine were defined.Geotropic or apogeotropic positional nystagmus was recorded by video-oculography and analysed three-dimensionally.Geotropic positional nystagmuses in patients with H-BPPV were classified as transient geotropic positional nystagmus with a TC of ?35?s or PGN with a TC of >35?s. Alternatively, the TC of persistent apogeotropic positional nystagmus (AN) in patients with H-BPPV was >35?s. The direction of the SPV of patients with PGN was opposite to that of patients with AN at each head position across the range of neutral head positions. The relationship between the SPV of patients with PGN and the angle of head rotation was linearly symmetrical against that of patients with AN with respect to a line drawn on the neutral head position.Since its TC was >35?s, it is suggested that PGN is induced by cupula deviation in response to gravity at each head position. It is also suggested that the direction of cupula deviation in patients with PGN is opposite to that of patients with AN across the neutral head positional range with no nystagmus where the long axis of cupula is in alignment with the axis of gravity. Since the pathophysiological basis of AN is considered a heavy cupula, it is suggested that PGN is conversely induced by a light cupula.

| S-EPMC4298092 | biostudies-literature

Posterior canal benign paroxysmal positional vertigo with long duration: Heavy or light cupula?

Project description:ObjectiveTo investigate the characteristics of positional nystagmus in posterior semicircular canal (PSCC) benign paroxysmal positional vertigo (BPPV) patients with longer durations, and to discuss the possible underlying mechanism of this nystagmus.MethodsWe conducted a retrospective review, and enrolled 118 consecutive patients with unilateral PSCC BPPV. The duration of nystagmus during a Dix-Hallpike test was classified into short (<1 min) and long (≥1 min) durations. For the identification of a neutral point in PSCC BPPV patients with long durations, the patient's head was turned 45° to the lesioned side to set the affected PSCC on the sagittal plane, and the disappearance of positional nystagmus was investigated in a pitch plane.ResultsAmong 118 patients with PSCC BPPV, positional nystagmus during a Dix-Hallpike test showed short durations (<1 min) in 112 patients and long durations (≥1 min) in 6 patients. Of 6 PSCC BPPV patients with a long duration, a neutral point was identified in 5 patients whose nystagmus lasted for longer than 2 min; interestingly, a neutral point was observed when the patient's head was slightly tilted backward in all 5 patients.ConclusionConsidering that a neutral position was identified when the patient's head was slightly tilted backward while keeping the head turned 45° to the right or left, we assume that the light cupula condition of the ipsilateral PSCC or the contralateral anterior semicircular canal, and not PSCC BPPV cupulolithiasis, could be responsible for the occurrence of persistent torsional-upbeating nystagmus in a Dix-Hallpike test.Level of evidence4.

| S-EPMC10446259 | biostudies-literature

Upbeat and Direction-Changing Torsional Nystagmus While Straight Head Hanging: A New Sign of Benign Paroxysmal Positional Vertigo Involving Bilateral Posterior Semicircular Canals.

Project description: Not available

| S-EPMC10782080 | biostudies-literature

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

Project description:ObjectiveThis 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 methodThe 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.ResultsThirty-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).ConclusionPersistent 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.

| S-EPMC9349017 | biostudies-literature

Spontaneous Jamming of Horizontal Semicircular Canal Combined with Canalolithiasis of Contralateral Posterior Semicircular Canal.

Project description:Spontaneous canalith jam is an uncommon form of benign paroxysmal positional vertigo mimicking acute vestibular neuritis. We described for the first time a spontaneous horizontal semicircular canalith jam associated with a typical canalolithiasis involving contralateral posterior semicircular canal (PSC), illustrating how the latter condition modified direction-fixed nystagmus during head movements. An 81-year-old woman with persistent vertigo referred to our center. Video-Frenzel examination showed horizontal direction-fixed right-beating nystagmus in primary gaze position, inhibited by visual fixation. She exhibited corrective saccades after leftward head impulses. Chin-to-chest positioning at the head-pitch test did not modify spontaneous nystagmus, whereas slight torsional components with the top pole of the eye beating toward the right ear appeared in backward head-bending, resulting in mixed horizontal-torsional nystagmus. At supine positioning tests, direction-fixed nystagmus turned into direction-changing geotropic horizontal nystagmus, which was stronger on the left side, while overlapping upbeat nystagmus with torsional right-beating components appeared on the right. Primary clinical findings were consistent with a left horizontal semicircular canalith jam, inducing a persistent utriculofugal cupular displacement, combined with a typical right-sided PSC-canalolithiasis. Once canalith jam crumbled, resulting in a non-ampullary arm canalolithiasis of the horizontal semicircular canal, both involved canals were freed by debris with appropriate repositioning procedures.

| S-EPMC8755438 | biostudies-literature

Lying-Down Nystagmus (LDN) - When a Lateralizing Sign of Secondary Importance Attains Ascendancy in the Diagnosis of Horizontal Semicircular Canal Benign Paroxysmal Positional Vertigo (HSC-BPPV).

Project description:BackgroundThe diagnosis of horizontal semicircular canal benign paroxysmal positional vertigo (HSC-BPPV) mainly depends on the elicitation of asymmetric horizontal positional nystagmus on rolling head to either side, during the diagnostic supine roll test (SRT). The asymmetry in the strength of the elicited horizontal positional nystagmus during SRT is explained by the Ewald's second law and is crucial for lateralizing the affected ear. Rarely the elicited horizontal positional nystagmus on the head roll to either side during the SRT is of symmetric strength. In such situations, the signs with secondary lateralizing value are useful in management by the repositioning maneuvers that require the affected side to be precisely known.AimThe submitted article is a case report.Results and discussionA 38-year-old male with two days history of vertigo on rolling to either of the lateral recumbent position was seen in the second week of March 2019. His SRT elicited a lying-down nystagmus (LDN) to the right, while the head roll to either side elicited a geotropic horizontal positional nystagmus of symmetric strength. The symmetrical strength of elicited positional nystagmus on SRT to either side led to ascendance of LDN from a lateralizing sign of secondary importance to one that reliably lateralized the involved horizontal semicircular canal. At two short term follow-ups at 1 hour and 24 hours after the therapeutic Gufoni maneuver, patient neither had vertigo nor any nystagmus elicited on the verifying supine roll test.ConclusionIn rare instances, LDN, which is a lateralizing sign of secondary importance becomes pivotal in the management of HSC-BPPV especially when the affected side needs to be precisely determined for the execution of the therapeutic repositioning maneuver.

| S-EPMC8370150 | biostudies-literature

Pseudo-spontaneous nystagmus in lateral semicircular canal benign paroxysmal positional vertigo: Correlation with bow and lean test in a pitch plane.

Project description:ObjectivesWe investigated the incidence and characteristics of pseudo-spontaneous nystagmus (PSN) in benign paroxysmal positional vertigo involving the lateral semicircular canal (LC-BPPV) and evaluated the correlation between PSN and the bow and lean test.MethodsWe examined nystagmus in the sitting position using video-oculography goggles in 131 LC-BPPV patients. The positioning test and bow and lean test were also performed. Patients were divided into canalolithiasis and cupulolithiasis groups according to the character of nystagmus. In each group, the incidence and direction of PSN, correlation with the bow and lean test, and treatment outcome were analyzed.ResultsPSN was observed in 25 cases (19.1%) in LC-BPPV patients, 7 of which were canalolithiasis and 18 of which were cupulolithiasis (p = 0.098). Of the 25 patients with PSN, 21 (84%) exhibited nystagmus consistent with the lean test whereas 4 (16%) exhibited nystagmus consistent with the bow test. In patients with PSN, nystagmus was observed in the bow and lean test in all cases (23/23), but in patients without PSN, no nystagmus was observed in 13 cases (13/87) in the bow and lean test (p = 0.048). The number of barbecue maneuvers performed until the end of treatment was 1.4 ± 0.7 in patients with PSN and 1.4 ± 0.9 in those without PSN (p = 0.976).ConclusionWe identified PSN in patients with LC-BPPV irrelevant of subtype. Moreover, all patients with PSN showed nystagmus in the bow and lean test. The direction of PSN was mostly consistent with that of the lean test (21/25, 84%). The presence of PSN was not related to the treatment outcome in this study.

| S-EPMC7676674 | biostudies-literature

Complex nystagmus in traumatic benign paroxysmal positional vertigo: A case study on the critical value of knowing semicircular canal excitation and inhibition patterns.

Project description:A 73-year-old female presented to the emergency department with chief complaint of dizziness after sustaining a fall one month prior to dizziness onset. Although careful examination of eye movement patterns during positional testing was attempted at varying stages of her inpatient admission, her complex nystagmus patterns as a result of traumatic benign paroxysmal vertigo were difficult to manage. In particular, the nystagmus pattern from this case suggests the BPPV was variable and affecting either 1) left posterior semicircular canal (pSCC) exclusively 2) left pSCC and right anterior semicircular canal, 3) left and right pSCC canal. This case illustrates the importance of two critical details; positional testing should include observing nystagmus with fixation removed and an experienced clinician should be involved as early as possible.

| S-EPMC8241704 | biostudies-literature

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