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Less talked variants of benign paroxysmal positional vertigo

  • Author Footnotes
    1 JM Kim and SH Lee contributed equally to this manuscript.
    Jae-Myung Kim
    Footnotes
    1 JM Kim and SH Lee contributed equally to this manuscript.
    Affiliations
    Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
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  • Author Footnotes
    1 JM Kim and SH Lee contributed equally to this manuscript.
    Seung-Han Lee
    Footnotes
    1 JM Kim and SH Lee contributed equally to this manuscript.
    Affiliations
    Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Republic of Korea
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  • Hyo-Jung Kim
    Affiliations
    Research Administration Team, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
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  • Ji-Soo Kim
    Correspondence
    Corresponding author at: Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do 463-707, Republic of Korea.
    Affiliations
    Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
    Search for articles by this author
  • Author Footnotes
    1 JM Kim and SH Lee contributed equally to this manuscript.
Published:September 29, 2022DOI:https://doi.org/10.1016/j.jns.2022.120440

      Highlights

      • Recognition of the variant forms of benign paroxysmal positional vertigo (BPPV) is essential for differentiation of BPPV from central positional nystagmus.
      • The patterns of pitch plane nystagmus, and presence of ‘null point’ aid in lateralization of horizontal-canal BPPV.
      • Downbeat nystagmus may be observed during Dix-Hallpike maneuver when the otoliths are located in the non-ampullary arm of the posterior canal or in the canal side of the anterior canal.
      • In cupulolithiatic posterior canal-BPPV, a ‘half Dix-Hallpike maneuver’ may be more effective in inducing positional nystagmus than the conventional Dix-Hallpike maneuver.
      • The ‘light cupula’ may generate persistent geotropic nystagmus, which should be differentiated from canalolithiatic horizontal canal-BPPV.

      Abstract

      The diagnostic criteria were established for benign paroxysmal positional vertigo (BPPV), the most common vestibular disorder worldwide, by the Barany Society in 2015. This marked an important milestone in the diagnosis and treatment of BPPV. However, there still remain uncertainties and ambiguities regarding the clinical features and pathophysiology of BPPV, and its clinical variants. In this manuscript, we will discuss 1) the emerging and controversial syndromes of BPPV (i.e., canalolithiasis of the anterior canal, cupulolthiasis of the posterior canal, and lithiasis of multiple canals) with updates, 2) atypical nystagmus according to the canal involved (e.g., nystagmus induced by head position changes in the pitch plane in horizontal canal BPPV, and positional downbeat nystagmus in posterior canal BPPV), 3) persistent geotropic positional nystagmus. Consideration of these uncommon types and manifestations of BPPV would broaden our understanding of BPPV pathomechanisms and allow differentiation from central vertigo and nystagmus.

      Keywords

      Abbreviations:

      AC (anterior canal), BPPV (benign paroxysmal positional vertigo), CRM (canalith reposition maneuver), HBN (head-bending nystagmus), HC (horizontal canal), HIT (head impulse test), LDN (lying-down nystagmus), pDBN (positional downbeat nystagmus), VOR (vestibulo-ocular reflex)
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