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

Darío H Scocco; María A Barreiro; Iván E García

doi:10.1016/j.joto.2022.02.001

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

J Otol. 2022 Apr;17(2):101-106. doi: 10.1016/j.joto.2022.02.001. Epub 2022 Feb 16.

Authors

Darío H Scocco¹, María A Barreiro¹, Iván E García¹

Affiliation

¹ Institute of Neuroscience, Favaloro Foundation University Hospital, Buenos Aires, Argentina.

Abstract

Background: Vestibular 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.

Objective: To describe new mechanisms of action for the sitting-up vertigo BPPV variant.

Methods: Eighteen 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.

Results: All 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).

Conclusions: Persistent 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.

Keywords: BPPV; BPPV, benign paroxysmal positional vertigo; Benign paroxysmal positional vertigo; CRM, canalith repositioning maneuvers; DBTN, down-beating torsional nystagmus; DHM, Dix-Hallpike maneuver; HH, half-Hallpike maneuver; HYT, head yaw test; Heavy cupula; ND, nose down position; Residual dizziness; SCC, semicircular canal; SHH, straight head hanging; Short arm canalolithiasis; Sitting up vertigo; Subjective BPPV; UBTN, up-beating torsional nystagmus; Vertigo.