Case Report: Bow Hunter Syndrome—One Reason to Add Non-gravity Dependent Positional Nystagmus Testing to Your Clinical Neuro-Otologic Exam

This case study describes transient downbeat nystagmus with vertigo due to a bilateral Bow Hunters Syndrome that was initially treated for 7 months as a peripheral benign paroxysmal positional vertigo. Normal static angiography and imaging studies (magnetic resonance, computed tomography) contributed to the mis-diagnosis. However, not until positional testing with the patient in upright (non-gravity dependent) was a transient downbeat nystagmus revealed with vertigo. The patient was referred for neurosurgical consult. Unfortunately, surgery was delayed due to suicidal ideation and hospitalization. Eventually, vertigo symptoms resolved following a C4-5 anterior cervical dissection and fusion. This case highlights the critical inclusion of non-gravity dependent position testing as an augment to the positional testing component of the clinical examination as well as the extreme duress that prolonged positional vertigo can cause.

A Young Patient with Horizontal Semicircular Cupulolithiasis with Immediate Response to the Therapeutic Head-Shaking Maneuver (HSM)

The apogeotropic variant of horizontal semicircular canal benign paroxysmal positional vertigo is attributed to either short anterior ampullary arm canalolithiasis or to the cupulolithiasis with the otoconial debris adhering to the cupula on utricular (Cup-U) or canal side (Cup-C), rendering it heavy and gravity sensitive. The treatment options for horizontal semicircular cupulolithiasis are not very well defined. A 25-year-old female patient with 8 days history of vertigo on rolling to either of the lateral recumbent position presented in the first week of November 2019. The supine roll test (SRT) on yawing head maximally to the right as well as to the left elicited an apogeotropic horizontal positional nystagmus lasting more than 1 minute, which was stronger on the right side and indicated a diagnosis of left horizontal semicircular cupulolithiasis. Two short-term follow-ups at 1 and 24 hours after head-shaking maneuver (HSM), with verifying SRT, were undertaken. During either of the two follow-ups, neither the previously elicited horizontal positional nystagmus was observed, nor did the patient have vertigo on rolling to lateral recumbent positions. She was telephonically questioned weekly regarding the recurrence of rotational vertigo for the next 4 weeks, and it was confirmed that she remained symptom free till then. The therapeutic HSM, owing to the inertial forces generated, can detach the otoconial debris from the cupula that renders it heavy and gravity sensitive. Successful offloading of cupula by HSM brings immediate cure in the Cup-U variant of the horizontal semicircular cupulolithiasis.

Physical Therapy for the Horizontal Semicircular Cupulolithiasis: A Prospective Interventional Case Series from an Otoneurology Center in South Rajasthan, India

Objective This article aims to study the effect of physical therapy in patients of horizontal semicircular cupulolithiasis with results audited in the short term. Design Nonrandomized prospective interventional study. Study Sample Four patients with horizontal semicircular cupulolithiasis. Results All four patients in whom diagnostic supine roll test (carried at least thrice to look for the sustainability as well as the polarity of the nystagmus) elicited apogeotropic horizontal positional nystagmus lasting more than 1 minute were subjected to therapeutic head-shaking maneuver (HSM). The results were audited immediately after the physical therapy, and at 1 hour. Follow-up by telephonic interviews for 4 weeks was done in all patients. Three out of four patients responded to HSM alone. One patient who did not respond to HSM was successfully treated with four other sequent physical therapies. Conclusion The response of physical therapy for horizontal semicircular cupulolithiasis occasionally indicates the side of the cupula to which otoconial debris is adherent (Cup-U or Cup-C). Occasionally, Cup-C variant of horizontal semicircular cupulolithiasis can be transformed by physical therapy to long posterior arm horizontal semicircular canalolithiasis—a disorder with better established treatment options.

Two Cases of Idiopathic Progressive Sensorineural Hearing Loss with Positional Nystagmus in Postpartum Period: Possible Spontaneous Perilymph Fistula?

Perilymph fistula (PLF) is defined as an abnormal communication between the middle ear cavity and perilymphatic space of the inner ear. Most cases of PLF are responsible for pressure change caused by internal trauma or external trauma. However, spontaneous PLF might occur without an obvious history of barotrauma. We report two cases of possible spontaneous PLF in the postpartum period: both cases involved progressive sensorineural hearing loss with positional dizziness. Although the leakage of perilymph was not found during exploration, both hearing loss and dizziness improved immediately after PLF repair. It is necessary to consider the possibility of PLF in patients who have sudden or progressive sensorineural hearing loss with positional nystagmus. Early surgical exploration is recommended even if the history of barotrauma is not clear.

Effect of Sitting Position vs. Supine Position With the Head Turned to the Affected Side on Benign Paroxysmal Positional Vertigo Fatigue

Objective: In benign paroxysmal positional vertigo (BPPV), positional nystagmus becomes generally weaker when the Dix–Hallpike test is repeated. This phenomenon is termed BPPV fatigue. We previously reported that the effect of BPPV fatigue deteriorates over time (i.e., the positional nystagmus is observed again after maintaining a sitting head position). The aim of this study was to investigate whether the effect of BPPV fatigue attenuates after maintaining a supine position with the head turned to the affected side.Methods: Twenty patients with posterior-canal-type BPPV were assigned to two groups. Group A received Dix–Hallpike test, were returned to the sitting position (reverse Dix–Hallpike test) with a sitting head position for 10 min, and then received a second Dix–Hallpike test. Group B received Dix–Hallpike test, were kept in the supine position with the head turned to the affected side for 10 min, and then received reverse Dix–Hallpike test followed by the second Dix–Hallpike test. The maximum slow phase eye velocity (MSPEV) of positional nystagmus induced by the first, reverse, and second Dix–Hallpike test were analyzed.Results: The ratio of MSPEV of the positional nystagmus induced by the second Dix–Hallpike test relative to the first Dix–Hallpike test was significantly smaller in group B than that in group A. There was no difference in the MSPEV of the positional nystagmus induced by the reverse Dix–Hallpike test between group A and B.Conclusions: The effect of BPPV fatigue is continued by maintaining a supine position with the head turned to the affected side, while the effect is weakened by maintaining a sitting head position. On the basis of the most widely accepted theory of the pathophysiology of BPPV fatigue, in which the particles become dispersed along the canal during head movement in the Dix–Hallpike test, we found an inconsistency whereby the dispersed otoconial debris return to a mass during the sitting position but do not return to a mass in the supine position with the head turned to the affected side. Future studies are required to determine the exact pathophysiology of BPPV fatigue.Classification of Evidence: 2b.

Nystagmus in adult patients with acute otitis media or otitis media with effusion without dizziness

The present study aimed to investigate the incidence and patterns of nystagmus in adult patients with acute otitis media (AOM) or otitis media with effusion (OME) without dizziness or vertigo, and discuss possible mechanisms. From February 2018 to November 2018, 34 consecutive patients with AOM or OME without dizziness were included. Nystagmus was examined with video Frenzel glasses. Of 34 adult AOM or OME patients without dizziness, nystagmus was observed in 28 patients (82%). In unilateral AOM or OME (n = 30), the most commonly observed nystagmus pattern was irritative-type direction-fixed nystagmus (n = 13), followed by paretic-type direction-fixed nystagmus (n = 8), and direction-changing positional nystagmus (n = 4). In bilateral AOM or OME (n = 4), direction-fixed nystagmus and direction-changing positional nystagmus were observed in two and one patients, respectively. Nystagmus was observed in as many as 82% of adult AOM or OME patients even though they did not complain of dizziness, and the pattern of nystagmus was either direction-fixed or direction-changing. Direct effect of inflammatory mediators penetrated from the middle ear and biochemical alteration in the inner ear fluids due to blood-perilymph barrier dysfunction may result in the presence of nystagmus in AOM or OME patients without dizziness.