Otology & Neurotology 36:1231Y1237 Ó 2015, Otology & Neurotology, Inc.

Diagnostic Role of Head-Bending and Lying-Down Tests in Lateral Canal Benign Paroxysmal Positional Vertigo Sertac Yetiser and Dilay Ince Department of Otorhinolaryngology, Anadolu Medical Center, Kocaeli, Turkey

geotropic nystagmus. Approximately 65.6% of patients with apogeotropic and 52% of patients with geotropic nystagmus had nystagmus during LDPT. However, its comparability with HRM was low. However, treatment plan based on LDPT results alone provided relief of symptoms in additional 12.5% of patients with apogeotropic and in 2.2% of patients with geotropic nystagmus. Approximately 63% of patients with apogeotropic and 56% of patients with geotropic nystagmus were able to tell the worse side. Nystagmus comparable with HRM during HBT was low and not diagnostic. Conclusion: HRM has the greatest diagnostic value of positioning tests in LC-BPPV in this study. LDPT provides some contribution in the diagnosis of LC-BPPV but much less than HRM. Patients’ subjective feeling of vertigo was also a useful test. However, HBT was not as sensitive as other measures in uncertain cases. Key Words: Positional vertigoVVertigoVParoxysmal.

Objectives: To compare the diagnostic value of the head-bending test (HBT), lying-down positioning test (LDPT) and patient’s report to identify the affected canal in video-nystagmographically (VNG) confirmed patients with lateral canal benign paroxysmal positional vertigo (LC-BPPV). Study Design: Case series with chart review. Setting: Head-bending, lying-down positioning and the head-roll maneuver (HRM) under VNG guidance. The data were collected in a referral community hospital. Patients: Seventy-eight patients (32 apogeotropic and 46 geotropic nystagmus) with LC-BPPV who had been recruited between 2009 and 2013 were enrolled in the study. Main Outcome Measures: Patients were tested with the HRM and then were asked about subjectively worse side. Later, they were subjected to HBT when sitting and the LDPT. The results were compared and studied with the 1-way ANOVA and chi-square tests. Statistical significance was set at p G 0.05. Results: Affected side was identified by HRM in 75% of patients with apogeotropic nystagmus and 95.6% of patients with

Otol Neurotol 36:1231Y1237, 2015.

Patients with benign paroxysmal positional vertigo of the lateral canal (LC-BPPV) are diagnosed as having geotropic or apogeotropic bidirectional nystagmus during the head-roll maneuver (HRM) in the supine position (1Y3). The type of nystagmus and the severity of vertigo sensation during this test will help diagnose the involved side when the head is turned (1). An analysis of slow phase velocity of the recorded nystagmus will also guide to determine the site with more intense nystagmus. A severe and brief sense of evoked vertigo is generally worse on the

affected side for geotropic type nystagmus and worse on the healthy side for apogeotropic type nystagmus. Identification of the affected side is very important in selection of the proper direction to apply the barbeque or liberatory maneuvers (4Y7). However, this task is not always easy to accomplish because the evoked nystagmus may be equally severe on both sides or may be too weak to diagnose. HRM in the supine position is very helpful in diagnosing the affected side in LC-BPPV. However, it has been reported that almost 10% of patients with unilateral LC-BPPV may have symmetrical nystagmus which makes it difficult to determine the side of the lesion (8). The examiner then needs to use additional methods for selection of the affected side, such as the head-bending test (HBT) when sitting, the lyingdown positioning test (LDPT), or the patient’s subjective feeling of vertigo (9). Patients with LC-BPPV frequently experience a sudden sense of spinning when they bend their head forward or backward intentionally or unintentionally such as when falling asleep while reading a newspaper when sitting, lying down from a sitting position, or getting out of bed. Those patients may have a brief nystagmus

Address correspondence and reprint requests to Sertac Yetiser, M.D., Department of Otorhinolaryngology and Head Neck Surgery, Anadolu Medical Center, Cumhuriyet mah, 2255 sok, No:3, Gebze 41400, Kocaeli, Turkey; E-mail: [email protected], [email protected] This study, similar or the same form, has not been submitted to any other journal for publication or presented in any medical meeting before. The data were collected and drafted by D. Ince. Data analysis, drafting, and final approval were completed by S. Yetiser. None of the authors have any financial, consultant, and institutional interest for the work or any grant or financial support provided by companies toward the completion of the work. Authors have no conflict of interest and no disclosures.

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associated with these conditions. From this observation, Nuti and Asprella proposed a test to confirm the diagnosis of the affected canal in LC-BPPV (10,11). They proposed a horizontal nystagmus beating to the healthy side in case of geotropic nystagmus (posterior arm canalolithiasis; otoliths located away from cupula) and to the affected side in case of apogeotropic nystagmus (anterior arm canalolithiasis; otoliths located close to the cupula or cupulolithiasis; otoliths attached to the cupula) when patients are lying down with their head in a straight head hanging position. When the head is erect in a sitting patient, an angle of 30 degrees exists between the horizontal plane and the lateral canal in which there will be no gravitational force and no movement of otoliths inside the canal (10,11). Bending the head 60 degrees forward brings the lateral canal to 30 degrees with reference to the horizontal plane, and this head motion causes ampullopetal floating of the otoliths resulting in a nystagmus toward the affected ear in geotropic nystagmus, or cupular deflection in the opposite direction, toward the unaffected ear in apogeotropic nystagmus (10,11). Changing the head position to 30 degrees backward will also change the angle of the lateral canal to an approximately vertical position, and the otoliths will move changing their direction and velocity (10,11). On the other hand, bringing the patient quickly from the seated position to the supine position will push the otoliths downward because of both gravity and deceleration forcing them toward the utricle if they are free in the canal or toward the ampulla if they are attached to the cupula. Therefore, this move will evoke a nystagmus beating toward the healthy side in the

case of geotropic nystagmus or toward the affected side in the case of apogeotropic nystagmus. The aim of this study is to compare the diagnostic value of HBT when sitting, LDPT, and the patients’ report of severity of sense of vertigo during HRM in the supine position in patients with LC-BPPV. MATERIALS AND METHODS Seventy-eight patients with LC-BPPV who had been recruited between 2009 and 2013 were enrolled in the study. A verbal and a signed informed consent were obtained from each patient. The procedures were in accordance with the ethical standards of the declaration of Helsinki and of the institutional review board. There were 36 men and 42 women with age ranging from 14 to 84 years (42.28 T 11.29). Duration of symptoms was ranging between 2 days and 12 weeks. Main inclusion criteria were normal otoscopic examination, normal hearing threshold, and no problems other than BPPV. Those with hearing loss, tinnitus, abnormal ear drum, or other vestibular or neurologic problems and those who used medication recently which could affect the vestibular system were excluded. Data were collected in a referral community hospital. All patients were first tested with VNG (Micromedical Technologies, Inc, USA) for spontaneous nystagmus in the seated primary gaze position before starting the test battery and those with spontaneous nystagmus were excluded from the study. Tests were performed in the order of spontaneous nystagmus, HRM, HBT, and LDPT. The type, duration, and direction of nystagmus were recorded with an infrared wireless video camera. VNG is done by goggles with closed camera system (open eyes, closed vision) and no fixation effect was allowed during the test. Between each test, the patient rested for 15 to 20 minutes to prevent fatigue.

FIG. 1. View of head-roll maneuver while the patient is lying down. Geotropic or apogeotropic nystagmus (bidirectional, horizontal) is seen in patients with LC-BPPV (APO, apogeotropic; GEO, geotropic). Dark arrow indicates the direction of the nystagmus. Otology & Neurotology, Vol. 36, No. 7, 2015

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HEAD-BENDING AND LYING-DOWN TESTS Presence of brief latency, short duration, and adaptation of transient nystagmus were always noted to confirm peripheral type positional nystagmus. Geotropic or apogeotropic nystagmus (bi-directional, horizontal) during HRM while the patient was lying down was initially documented (Fig. 1). The patient’s head was first turned to the right side for 3 minutes and then to the center position. Later, the head was turned to the left side to see evoked nystagmus. The affected side was determined according to the severity of nystagmus as seen on the VNG recording. Nystagmus of greater velocity was on the affected side in patients with geotropic nystagmus and on the healthy side in patients with apogeotropic nystagmus. Patients were defined as ‘‘undetermined laterality for geotropic or apogeotropic form’’ if the analysis of the recorded images shows similar slow phase eye velocity on both sides. Patients were also asked about how they felt and which side was worse for the sense of vertigo during HRM. Later, the patients were subjected to HBT at sitting in 3 different positions (Fig. 2). First, the head was quickly bent forward by 60 degrees (Position A) while the patient was in the sitting position. Then, the patient’s head was put in the straight position (position B). This was actually a movement action from position A to position B (different from primary gaze position to seek for spontaneous nystagmus). Finally, the head was bent backward by 30 degrees (position C). This was again a movement action from position B to position C. The test was performed with VNG, and each position was held for 5 minutes to obtain sufficient time to record the evoked nystagmus. The head was grasped and fixed by the technician at each position. Finally, the patient was asked to lie down from the sitting position (LDPT) and again evoked nystagmus was recorded by VNG (Fig. 3). Horizontal positional nystagmus seen during LDPT was toward the healthy side in patients with geotropic nystagmus and toward the affected side in

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patients with apogeotropic nystagmus. Positional nystagmus during HBT in patients with geotropic nystagmus was toward the affected side in position A and toward the healthy side in positions B and C. However, in patients with apogeotropic nystagmus, it was toward the healthy side in position A and toward the affected side in positions B and C. Patients having nystagmus with asymmetric intensity on both sides during HRM in the supine position under VNG (the affected side was clear for geotropic or apogeotropic type nystagmus) and those having nystagmus with almost equal intensity were determined. Patients having no nystagmus during LDPT and/or HBT and those having nystagmus during the tests confirming the affected side as detected by HRM were determined. Finally, patients who were unable to tell the affected side from the severity of sense of vertigo during the HRM (equal intensity or very mild sense of spinning), and those who reported asymmetric severity of sense of vertigo during the HRM were determined. Mean values were compared for each group. Patients with apogeotropic nystagmus were treated with Barbeque, Semont’s, or Gufoni maneuvers, and patients with geotropic nystagmus were treated with Barbeque or Gufoni maneuvers. All patients were controlled within 5 to 7 days after therapeutic maneuvers. The 1-way ANOVA and chi-square ‘‘goodness of fit’’ tests were used for comparative analysis of the groups. Statistical significance was set at p G 0.05.

RESULTS Thirty-two patients had apogeotropic, and 46 patients had geotropic type nystagmus, which were noted in HRM. Identification of the affected side was possible in 24 of the 32 patients with apogeotropic type nystagmus (75%) by

FIG. 2. View of head bending test at sitting in 3 positions in a patient assuming with healthy left side. A, bending forward; B, straight; C, bending backward. APO indicates apogeotropic; GEO, geotropic. Dark arrow indicates the direction of the nystagmus. Otology & Neurotology, Vol. 36, No. 7, 2015

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FIG. 3. View of lying down positioning test in a patient assuming with healthy left side (APO, apogeotropic; GEO, geotropic). Dark arrow indicates the direction of the nystagmus.

HRM (11 in right ear and 13 in left ear). Eighteen patients with apogeotropic nystagmus were able to tell the worse side in terms of sense of severity during HRM (18/32; 56%). Eight patients had nystagmus during HBT position A (8/32; 25%) and 7 patients had nystagmus during HBT position C (7/32; 21.7%). None of the patients had any nystagmus during HBT position B. Twenty-one patients had nystagmus during LDPT (21/32; 65.6%), but it was comparable with the side of the affected canal detected by HRM in 15 patients (15/32; 46.7%), and it was vertical or not comparable with HRM in 6 patients (Fig. 4). Identification of the affected side was possible in 44 of the 46 patients with geotropic type nystagmus (95.6%) by HRM (21 in right ear and 22 in left ear). Twenty-nine patients were able to tell the worse side in terms of sense of severity during HRM (29/46; 63%). Thirteen patients had nystagmus during HBT position A (13/46; 28.3%), and 15 patients had nystagmus during HBT position C (15/46; 32.6%). None of the patients had nystagmus during HBT position- B. Twenty four patients had nystagmus during LDPT (24/46; 52%), but it was comparable with the side of the affected canal detected by HRM in 10 patients (10/46; 21.7%). It was slightly beating up (4 patients) or down (2 patients) or horizontal but not comparable with HRM (8 patients) (Fig. 5). Twenty-three patients with apogeotropic nystagmus and laterality sign on HRM responded the treatment. The

treatment plan was based on LDPT findings in 6 of 7 patients with equal nystagmus on both sides during HRM and was effective in 4 after several attempts. Therefore, the number of patients with cure increased from 71.8% (23/32) to 84.3% (27/32), when HRM and LDPT are combined as diagnostic tools, if improvement of symptoms after therapeutic maneuvers are assumed to enhance the determination of the laterality. Forty-three patients with geotropic nystagmus and laterality sign on HRM were responded the treatment. Treatment plan was based on the LDPT findings in 2 patients and was effective in one of them. Therefore, the number of patients with cure increased from 93.4% (43/46) to 95.6% (44/46), when combination of the HRM and LDPT are used as the diagnostic tests. Comparative analysis of the test results for patients with geotropic and apogeotropic type nystagmus is presented in Table 1. Diagnostic value of both the LDPT and patients’ reports was better in patients with apogeotropic nystagmus and also in those with geotropic nystagmus, compared with the value of HBT. No statistically significant difference was found when comparing the diagnostic value of HBT in the 3 positions, LDPT and patients’ reports between patients with geotropic and those with apogeotropic nystagmus (p 9 0.05). The number of patients who were cured after treatment and in whom diagnostic evaluation was based on LDPT alone was statistically significantly better in patients with apogeotropic nystagmus compared with patients

Otology & Neurotology, Vol. 36, No. 7, 2015

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HEAD-BENDING AND LYING-DOWN TESTS

FIG. 4.

The overall test results of patients with apogeotropic type nystagmus.

having geotropic nystagmus (p = 0.018). However, when all diagnostic tests were used together, the overall cure rate in patients with geotropic type nystagmus was statistically significantly better than patients with apogeotropic type nystagmus (p = 0.044). DISCUSSION Studies related with the diagnostic issues of LC-BPPV are generally based on HRM only and comparative analysis with other methods is lacking. Few studies have been published analyzing the diagnostic value of LDPT to determine the affected canal in patients with LC-BPPV. Han et al. have analyzed the presence of lying-down nystagmus (toward

FIG. 5.

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the healthy ear in geotropic and toward the affected ear in apogeotropic type) in 152 patients with LC-BPPV and have observed this nystagmus in 38.2% of patients with documented LC-BPPV (36.4% of the geotropic and 41.5% of the apogeotropic type) (9). We have found higher incidence of evoked nystagmus during LDPT in our series (65.6% for apogeotropic nystagmus and 52% for geotropic nystagmus), although the number of patients is smaller. However, its contribution to the diagnosis was less than HRM. It seems that it is not always possible to evoke the nystagmus with LDPT. This could be related with the density and the amount of the otoliths or their distance to the cupula inside the membranous labyrinth to evoke nystagmus or with the examiner who is unable to do the test adequately

The overall test results of patients with geotropic type nystagmus. Otology & Neurotology, Vol. 36, No. 7, 2015

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S. YETISER AND D. INCE TABLE 1.

Comparative analysis of the test results for patients with geotropic and apogeotropic nystagmus

Tests Rate of nystagmus seen with HBT-A Rate of nystagmus seen with HBT-C Rate of nystagmus seen with LDPT Patient’s subjective feeling of more severe side Patients benefit based on LDPT Overall cure rate

Geotropic nystagmus (46 patients)

Apogeotropic nystagmus (32 patients)

28.3% 32.6% 52% 63% 2.2% 95.6% (44/46)

25% 21.7% 65.6% 56% 12.5% 84.3% (27/32)

p

a a

0.275 0.088 0.655 0.109 0.018 0.044

HRM indicates head-roll maneuver; LDPT, Lying down positioning test; HBT- a, head bending test at position A; HBT- C, head bending test at position- C. a Significant p values.

because the lying down movement should be so quick. We have also some concern about the order of the tests. We have done first HBT, then later LDPT. This may cause dispersal of the debris in some patients. Doing several tests always in the same order is one of the limitations of this study. The order of tests would be randomized to reduce the effect of one test to another one. Several tests may also raise a question of fatigability and adaptation, although we always cared about resting patients for 15 to 20 minutes. Another limitation could be blinding of investigators. Ideally, a person interpreting a test should be blinded to the results of all the other tests. Testing and interpretation were made by different people in this study. However, interpretation of all tests was made by the same person. Finally, some limitations may exist to raise a general conclusion for the utility of a clinical test in a single center study, which needs to be reviewed by a multi center study. Choung et al. have reviewed the effect of the so-called ‘‘bow and lean test’’ (affected ear was in the same direction as bowing nystagmus in geotropic nystagmus and the same direction as leaning nystagmus in apogeotropic nystagmus) to determine the side of the affected canal in 26 patients with LC-BPPV. This test, which was actually similar to the HBT, revealed no nystagmus in 3 patients (11.5%) and was not comparable with HRM in the supine position in 7 patients (26.9%) (12). Lee et al. have reviewed the lateralizing value of head bending nystagmus in 54 patients with LCBPPV while sitting (13). Fifteen patients had no headbending nystagmus (27.8%), and it was not comparable with head turning asymmetric nystagmus in the supine position in 5 patients. The overall diagnostic value was 63% (34/54). Identification of the affected side with HRM is generally possible in patients with LC-BPPV in the presence of nystagmus with asymmetric intensity and the relief of symptoms after therapeutic maneuver confirms the determination of the laterality. It seems that the cure rate is high for both geotropic and apogeotropic type LC-BPPV if the laterality is clearly evident by HRM. Forty-three of 44 patients with geotropic and 23 of 24 patients with apogeotropic nystagmus responded well at least to one of the therapeutic maneuvers. However, HRM indicated the involved side in 75% of patients with apogeotropic nystagmus and 95.6% of patients with geotropic nystagmus in this series. Therefore, it is an important measure to always include other diagnostic signs in the test battery to increase the rate of identification of the involved side.

Our findings do not support the diagnostic contribution of HBT in identification of the affected side. It has been concluded in this study that the diagnostic role of patient’s subjective feeling of vertigo, which has not been paid much attention in previous studies, is reliable and the diagnostic reliability of patient’s report and LDPT is statistically more significant than HBT. However, despite all these diagnostic tests, there were 3 patients with bi-directional geotropic (1 patient) and apogeotropic nystagmus (2 patients) with symmetric severity where the affected side remained undiagnosed. Several attempts at therapeutic maneuvers were required on both sides in these patients, and the cure was eventually delayed. Although it has been scarcely reported, this raises a possibility of a bilateral disease. CONCLUSION In conclusion, HRM has the greatest diagnostic value of positioning tests in LC-BPPV in this study. LDPT provides some contribution in the diagnosis of LC-BPPV but much less than HRM. LDPT was useful when combined with the HRM, especially if the patients had symmetric nystagmus on turning their head to either side. Patients’ subjective feeling of vertigo was also a useful test. Therefore, patient’s report and LDPT should be included in the test battery of patients with LC-BPPV. However, HBT was not as sensitive as other measures in uncertain cases in this series. Acknowledgments: The authors thank all personnel of the department for their valuable help to the patients. The authors also thank to Mr. Murat Gul, associate professor, Giresun University, Department of Statistics ([email protected]) for his review of the data.

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HEAD-BENDING AND LYING-DOWN TESTS 6. Appiani GC, Catania G, Gagliardi M. A liberatory maneuver for the treatment of horizontal canal paroxysmal positional vertigo. Otol Neurotol 2001;22:66Y9. 7. Casani AP, Vannucci G, Fattori B, Berrettini S. The treatment of horizontal canal positional vertigo. Our experience in 66 case. Laryngoscope 2002;112:172Y8. 8. Balatsouras DG, Koukoutsis G, Ganelis P, Korres GS, Kaberos A. Diagnosis of single- or multiple-canal benign paroxysmal positional according to the type of nystagmus. Int J Otolaryngol 2011; 2011:483965. 9. Han BI, Oh HJ, Kim JS. Nystagmus while recumbent in horizontal canal benign paroxysmal positional vertigo. Neurology 2006;66:706Y10.

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10. Nuti D, Vannucchi P, Pagnini P. Lateral canal BPPV: Which is the affected side? Audiol Med 2005;3:16Y20. 11. Asprella-Libonati G. Diagnosis and treatment strategy of the lateral semicircular canal canalolithiasis. Acta Otorhinolaryngol Ital 2005; 25:277Y83. 12. Choung YH, Shin YR, Kahng H, Park K, Choi SJ. ‘‘Bow and lean test’’ to determine the affected ear of horizontal canal benign paroxysmal positional vertigo. Laryngoscope 2006;116:1776Y81. 13. Lee SH, Choi KD, Jeong SH, Oh YM, Koo JW, Kim JS. Nystagmus during neck flexion in the pitch plane in benign paroxysmal positional vertigo involving the horizontal canal. J Neurol Sci 2007; 256:75Y80.

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Diagnostic Role of Head-Bending and Lying-Down Tests in Lateral Canal Benign Paroxysmal Positional Vertigo.

To compare the diagnostic value of the head-bending test (HBT), lying-down positioning test (LDPT) and patient's report to identify the affected canal...
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