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Lying-down nystagmus and head-bending nystagmus in horizontal semicircular canal benign paroxysmal positional vertigo: are they useful for lateralization?
© Oh et al.; licensee BioMed Central Ltd. 2014
Received: 15 July 2014
Accepted: 11 November 2014
Published: 20 November 2014
Lateralization of horizontal semicircular canal benign paroxysmal positional vertigo (HSC-BPPV) is very important for successful repositioning. The directions of lying-down nystagmus (LDN) and head-bending nystagmus (HBN) have been used as ancillary findings to identify the affected sites. This retrospective study was performed to evaluate the lateralizing values of LDN and HBN using clinical and laboratory findings for lateralizing probabilities in patients with HSC-BPPV.
For 50 HSC-BPPV patients with asymmetric direction-changing horizontal nystagmus (DCHN) during the head-rolling test (HRT) using Frenzel goggles, the directions of LDN and HBN were evaluated and compared to those determined by video-oculography. Directional LDN was defined as the contralesional direction of nystagmus in geotropic types and the ipsilesional direction in apogeotropic types. Directional HBN was defined as the opposite direction relative to directional LDN. We also analyzed LDN and HBN in 14 patients with a history of ipsilesional peripheral vestibulopathy, caloric abnormality or conversion from other types of BPPV (such as probable localized HSC-BPPV, pro-BPPV).
LDN and HBN were seen in 68% (34/50) and 76% (38/50) of patients, respectively. Of these, 19 (55.9%), and 28 (73.7%) patients showed directional LDN and HBN, respectively. The proportion of patients with directional LDN and HBN was much smaller among the pro-BPPV patients (4/12 for LDN, 3/10 for HBN).
LDN and HBN did not seem to predict lateralization in patients with HSC-BPPV. To improve the prediction of lateralization of HSC-BPPV, it is necessary to modify the maneuvers used to elicit LDN or HBN, especially in cases of symmetric DCHN during HRT.
BPPV often recurs  and can be secondary to Meniere’s disease or vestibular neuritis . Furthermore, PSC-BPPV can often be transformed to HSC-BPPV [15, 16], and canal paresis generated by impaired endolymphatic flow is reported to recover after cure of HSC-BPPV [16, 25–27]. Taking the clinical characteristics of BPPV into consideration, we conducted a retrospective review of clinical records and caloric tests of HSC-BPPV patients to assess HBN and LDN in lesion lateralization using asymmetric DHCN during HRT.
Positioning nystagmus test
Nystagmus was evaluated with infrared video-Frenzel goggles (Easy-Eyes®, SLmed, Seoul, Korea) in accordance with the practice guidelines for vertigo at Department of Neurology, JNUH. The HRT was performed in the supine position with the head elevated 30° from the horizontal. The head was turned by 90° to the left side for 50 s to examine the nystagmus. Then, the head was returned to the neutral position for 30 s. If the nystagmus was still observed in the neutral position, we waited until it disappeared. Then, the head was turned by 90° to the right side for 50 s and the nystagmus was examined. Subsequently, patients were asked to sit in the head-upright position with the eyes looking forward during 30 s and then to bend the head at 60° forward the pitch axis for 50 s for the observation of nystagmus (HBN). Thereafter, the patients were asked to take an upright-sitting position with the eyes looking forward for 30 s and then to quickly lie down for 50 s; the nystagmus (LDN) was then examined.
To discriminate between PSC-BPPV and anterior semicircular canal BPPV (ASC-BPPV), the Dix-Hallpike maneuver  was also performed on each side consecutively. Based on Ewald’s second law, lateralization of the lesion side was determined as the result of DCHN during HRT [10–12]. Directional HBN was defined as the nystagmus direction toward the affected ear in HSC-BPPV for geotropic types. Directional LDN was defined as the contralesional direction of nystagmus for the geotropic type. For apogeotropic types, directional HBN and LDN were in the opposite directions relative to the geotropic types [4, 21, 22].
Recordings of nystagmus
where SPV is the slow phase velocity.
Bithermal caloric test
An alternating bithermal caloric test was conducted with Air-star® (Micromedical Technologies, Belgium); the test was performed again when vertigo was completely cured. Nystagmus SPV was measured every 180 s in the following order: cold left, cold right, warm left, and warm right ears. The temperature of cold and warm air waves was 27°C and 48°C, respectively. Stimulation time was 50 s. The percentage of canal paresis was calculated using the Jonkee’s formula ; canal paresis was defined as a greater than 25% difference between in maximal nystagmus slow phase eye velocity between the right and left sides. Bilateral canal paresis was diagnosed when the sum of slow phase velocities for each ear was below 12°/s.
Medical history of BPPV, vestibular neuritis, Meniere’s disease, and peripheral vertigo was confirmed based on EMR.
Selection of patients with high probability of lateralization
To thoroughly evaluate HSC-BPPV lateralization, the following criteria are suggested. Among 50 patients who met the inclusion criteria, probable localized HSC-BPPV(pro-BPPV) was diagnosed if at least one of the following conditions was satisfied, whereas possible localized HSC-BPPV(pos-BPPV) was diagnosed if none of them was met: 1) conversion into PSC- or ASC-BPPV on the lesion side after HSC-BPPV diagnosis, 2) canal paresis on the same side in the initial caloric test, and normal condition in the second test, 3) history of vestibular neuritis or Meniere’s disease according to EMR, or recurrence of PSC-, ASC- or HSC-BPPV on the same side.
Descriptive statistics were presented for continuous variables according to each demographic variable, and frequency and percentage were presented for categorical variables. Cohen’s kappa coefficient was used to identify concordance for the direction of LDN and HBN between video-oculography and Frenzel goggles. Statistical analyses were conducted using SPSS version 18.0. Differences were considered statistically significant at p < 0.05.
Direction of lying down nystagmus(LDN) and head bending nystagmus(HBN) in 50 patients
Geotropic (N = 31)
Apogeotropic (N = 19)
Total (N = 50)
Bithermal caloric test
Bithermal caloric tests were performed in all patients and were repeated in all but one patient. The time interval between the first and second caloric tests ranged from 2 to 42 days (mean, 15.3; median, 12). None of the patients had bilateral canal paresis. Canal paresis was detected on the affected side in 13 patients in both caloric tests and in 6 patients only in the first test. In these 6 patients, canal paresis was normalized in the second test (Figure 2).
Analysis of LDN and HBN
Direction of lying down nystagmus(LDN) and head bending nystagmus(HBN) in 14 patients with probable localized HSC-BPPV
Geotropic (N = 8)
Apogeotropic (N = 6)
Total (N = 14)
Video-oculography was performed in 40 patients. Ten patients who were not examined by video-oculography all had pos-BPPV. There was a highly significant coefficient of concordance between the directions of LDN and HBN measured with video-oculography and Frenzel goggles in all patients (N = 40, LDN, κ = 0.66; p = 0.00, HBN, κ = 0.84; p = 0.00), pro-BPPV patients (N = 14, LDN, κ = 0.67; p = 0.00, HBN, κ = 0.69; p = 0.01), and pos-BPPV patients (N = 26, LDN, κ = 0.65; p = 0.00, HBN, κ = 0.88; p = 0.00).
Lateralization of HSC-BPPV is determined based on the difference in DCHN intensity during HRT, and is critical in the choice of the therapeutic maneuver. However, it is often difficult to identify the difference in clinical practice. A number of studies have attempted to investigate lateralization of the lesion side on the basis of the various types of nystagmus manifested in different positioning tests [4, 21–23, 30]. A considerably larger number of studies have addressed the effectiveness of LDN and HBN. According to a study by Koo et al. on 54 patients with HSC-BPPV, directional LDN was observed in 75% of geotropic and 80% of apogeotropic types . In their retrospective study, the design of which was similar to that of our study, lateralization effectiveness of LDN appeared to be superior to that in our study. In a prospective study by Han et al. on 152 patients, directional LDN occurred in 56 (96.6%) out of 58 patients with LDN . In Lee et al.’s measurements (using video-oculography) of DCHN during HRT, LDN and HBN in 54 HSC-BPPV patients, lateralization rates were 82.9% (geotropic, 73.7%; apogeotropic, 93.8%) and 87.8% (geotropic, 88.9%; apogeotropic, 93.8%) in LDN and HBN, respectively, among 45 patients showing asymmetric DHCN during HRT .
In our study, lateralization rates of LDN and HBN were 55.9% (geotropic, 63.2%; apogeotropic, 46.7%) and 73.7% (geotropic, 73.9%; apogeotropic, 73.3%), respectively. Moreover, lateralization rates of LDN and HBN were 33.3% (geotropic, 33.3%; apogeotropic, 33.3%) and 30.0% (geotropic, 20.0%; apogeotropic, 40.0%), respectively, in patients with high probability of lateralization based on caloric tests, previous history of vestibular disease, and conversion to other semicircular canal BPPVs; these results differed from the results of previous studies [4, 21, 22]. Among 50 patients, LDN and HBN were not elicited in 16 (32%) and 12 (24%) patients. According to Koo et al., LDN was not seen in 16 (57%) out of 28 patients with the geotropic type, and in 6 (23%) out of 26 patients with the apogeotropic type . In a study by Han et al., LDN was found in only 58 out of 152 patients with HSC-BPPV . Moreover, LDN and HBN were not seen in 10 and 12 patients, respectively, among 45 patients in a study by Lee et al. performed using video-oculography . Therefore, whether LDN and HBN are useful for lateralization in HSC-BPPV remains unclear.
This study evaluated nystagmus in all patients with HSC-BPPV using Frenzel goggles, which are conveniently used at bedside, and the outcomes were compared to those of video-oculography. Moreover, this study was able to assess the effectiveness of LDN and HBN in lateralization of the lesion side after clarifying lateralization using laboratory and clinical findings, and previous history of vestibulopathy. We found that LDN and HBN did not seem to predict lateralization of the lesion side in patients with HSC-BPPV clinically. LDN and HBN were not elicited in a large number of patients. The frequency of lateralization to the wrong direction was high. Since this study was performed retrospectively, therapeutic methods and their efficacy cannot be thoroughly examined. According to Choung et al., DCHN detected in HRT as well as Bow and Lean tests (BLT) indicated different lesion sides in patients with HSC-BPPV. When a repositioning maneuver was performed after lateralization of the affected side based on BLT, symptoms were improved . Moreover, a repositioning maneuver depending on LDN and HBN also improved symptoms in 7 out of 9 patients with a symmetric DHCN on HRT in a study by Lee et al. . Therefore, the analysis of treatment methods and its efficacy is crucial in evaluation of lateralization efficacy. In addition, there were only 14 patients with high probability of lateralization. The small sample size could have limited the evaluation of the lateralization rates of LDN and HBN.
Lying-down nystagmus and head-bending nystagmus do not seem to predict lateralization in patients with horizontal semicircular canal benign paroxysmal positional vertigo. To improve the lateralization rate in HSC-BPPV, maneuvers for eliciting LDN or HBN need to be modified and prospective studies using other lateralizing tests are crucial in the future.
This research was supported by the 2014 scientific promotion program (Jeju National University).
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