Treatment Dan Diagnosis Vertigo

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ORIGINAL ARTICLE

International Tinnitus Journal. 2011;16(2):1!"#!.

$eni%n &aro'sal &ositional *erti%o: +ia%nosis an+treatent

Roseli ,arai*a -oreira $ittar 1

Rauel -e//alira 2

aula Loo urta+o

Alessan+ra Raos 3enosa #

An+re Luis Lo&es ,a&aio #

Carlos Au%usto Costa ires +e Oli*eira #

Astra4t

$eni%n &aro'sal &ositional *erti%o is a 4oon +isor+er in Neurotolo%. T5is *estiular sn+roe is

45ara4teri/e+ transient atta4s o7 *erti%o8 4ause+ 45an%e in 5ea+ &osition8 an+ asso4iate+ 9it5 &aro'sal

45ara4teristi4 nsta%us. T5e s&tos result 7ro o*eent o7 t5e 7ree 7loatin% oto4onia &arti4les in t5e

en+ol&5 or t5eir atta45ent to t5e 4u&ulae o7 t5e sei4ir4ular 4anal. T5e +ia%nosis is essentiall 4lini4al an+

s5oul+ e 4on7ire+ &er7orin% +ia%nosti4 aneu*ers. Treatent is ase+ on t5e i+enti7i4ation o7 t5e a77e4te+

sei4ir4ular 4anal an+ &er7oran4e o7 lierator aneu*ers or re&ositionin% o7 7ree 7loatin% &arti4les o7 otolit5s.

T5e e77e4ti*eness *aries 7ro 0 to 100.

Keywords: +i//iness8 *erti%o8 *estiular +iseases.

1 <ni*ersit o7 ,=o aulo8 $ra/il. E"ail: roseli.ittar>%ail.4o

2 <ni*ersit o7 Ca&inas8 $ra/il. E"ail: rauele//alira>uol.4o.r

?os&ital +e $ase o7 @istrito e+eral8 $ra/il. E"ail: &l.7urta+o>%ail.4o

4 <ni*ersit o7 $rasilia8 $ra/il. E"ail: alessan+ra*enosa>%ail.4o an+rearB>uol.4o.r 4a4&oli*eira>rturo.4o.r



International Tinnitus Journal8 3ol. 168 No 2 (2011)

999.tinnitusBournal.4o

135

INTRO@<CTION

$eni%n aro'sal ositional 3erti%o ($3) isone o7 t5e ost &re*alent 4lini4al +isor+ers in 4oonNeurotolo% &ra4ti4e an+ a44ounts 7or a&&ro'iatel 1

o7 4o&laints o7 *erti%o1. It re&resents t5e ost i&ortant

&eri&5eral *estiular i&airent alon% t5e li7es&an18288alt5ou%5 t5e a%e at onset is 4oonl e"t9een t5e 7i7t5

an+ se*ent5 +e4a+es o7 li7e#. ?o9e*er8 t5e tie o7 onset

5as also een +es4rie+ at 45il+5oo+!868. It a77e4ts 7ro

10. to 6# &er 1008000 &atients a ear (li7etie&re*alen4e o7 2.# &er4ent) D8F. oen are ore

a77e4te+ t5an t5e en in a &ro&ortion o7 1.! to 2.21.

Gi*en t5e note9ort5 &re*alen4e o7 $38 its

5ealt5 4are an+ so4ietal i&a4ts are treen+ous. It isestiate+ t5at it 4osts a&&ro'iatel <,H2000 to arri*eat t5e +ia%nosis o7 $38 an+ t5at 6 &er4ent o7 &atients su77er soe interru&te+ +ail a4ti*ities an+ lost

+as at 9or e4ause o7 $3

.ositional *erti%o is +e7ine+ as a s&innin% sensa"

tion &ro+u4e+ 45an%es in 5ea+ &osition relati*e to%ra*it. $eni%n &aro'sal &ositional *erti%o is +e7ine+as a +isor+er in t5e inner ear8 45ara4teri/e+

re&eate+ e&iso+es o7 &ositional *erti%o8 9it5 t&i4al&aro'sal nsta%us.

$3 a e +ia%nose+ an+ treate+ ulti&le4lini4al +is4i&lines. @es&ite its si%ni7i4ant &re*alen4e8 an+ualit o7"li7e an+ e4onoi4 i&a4ts8 4onsi+erale &ra4"ti4e *ariations e'ist in t5e ana%eent o7 $3 a4ross

+is4i&lines. T5ese *ariations relate to ot5 +ia%nosti4

strate%ies 7or $3 an+ rates o7 utili/ation o7 *arious

treatent o&tions a*ailale 7or $3 9it5in an+ a4rosst5e *arious e+i4al s&e4ialties an+ +is4i&lines in*ol*e+ inits ana%eent. @elas in t5e +ia%nosis an+ treatent o7 $3 5a*e ot5 4ost an+ ualit"o7"li7e i&li4ations 7or

ot5 &atients an+ t5eir 4are%i*ers.

,i%ni7i4ant i&ro*eents in t5e +ia%nosis an+treatent o7 &atients 9it5 $3 a lea+ to si%ni7i4ant5ealt5 4are ualit i&ro*eents as 9ell as e+i4alan+ so4ietal 4ost sa*in%s. ,u45 i&ro*eents a ea45ie*ale 9it5 t5e re+u4tion o7 t5e ina&&ro&riate useo7 *estiular su&&ressant e+i4ations8 +e4reasin% t5eina&&ro&riate use o7 unne4essar tests su45 asra+io%ra"&5i4 ia%in%8 an+ in4reasin% t5e use o7 a&&ro&riate 4ost e77e4ti*e t5era&euti4 re&ositionin%aneu*ers. In t5is 4onte't8 $3 s5oul+ e entione+not onl e4ause o7 t5e 5i%5 &re*alen4e8 ut alsoe4ause o7 t5e relati*e si&li4it o7 t5e +ia%nosis an+

4ost e77e4ti*eness o7 t5e treatent.T5e &ur&ose o7 t5is &a&er is to re*ie9 t5e a*ailale

et5o+s 7or +ia%nosis an+ treatent o7 $3 inten+e+

7or 4lini4ians 95o are liel to +ia%nose an+ ana%e

&atients 9it5 $38 an+ a&&lies to an settin% in 95i45

$3 9oul+ e i+enti7ie+8 onitore+8 or ana%e+. To

+o t5is8 9e &er7ore+ a non"ssteati4 literaturere*ie9 +ealin% 9it5 $3.

CLINICAL RE,ENTATION AN@ AT?OLOG

T5e +i77eren4e o7 +ensit o7 t5e 4u&ulae an+

larint5 en+ol&5 lea+s to t5e s&tos. @is&la"4e+&arti4les 7ro utri4ule otolit5s 7loat aroun+ in t5e

en+ol&5 (4analit5iasis)11 or a+5eren to t5e 4u&ulae

(4u&ulolit5iasis)12 an+ a 45an%e t5e +ensit relationo7 t5e 4u&ulae"en+ol&5 sste. T5e sei4ir4ular 4anals 45an%e t5eir %ra*itational orientation &lane95ile t5e &atients o*e t5eir 5ea+. T5e +eris+islo4ates an+ &rootes anoalous a4ti*ation o7 t5ea&ullar 4rista an+ a inter7ere 9it5 t5e neuronalout&ut in+e' t5at norall 9oul+ e e'&e4te+ 7or t5at5ea+ an+ 4anal &osition. ,u45 sensor 4on7li4t lea+s toalan4e +isor+er an+ nsta%us.

O7 t5e t9o *ariants o7 $38 4analit5iasis is t5eost 4oon8 an+ t5e &osterior sei4ir4ular 4anal is t5eost a77e4te+ e4ause o7 its anatoi4al &osition (!"!

o7 4ases o7 $3). T5e a&ulla o7 t5e &osterior sei4ir4ular 4anal is lo4ate+ in t5e lo9er re%ion o7 t5e*estiule8 ot5 in t5e su&ine an+ stan+in% &osition. T5e7ra%ents in sus&ension insi+e t5e lairint5 ten+ to e

+e&osite+ in t5is re%ion8 t5e a4tion o7 %ra*it 18181#81!.T5e lateral sei4ir4ular 4anal a e in*ol*e+ in ! to 1!

o7 &atients an+ t5e anterior 4anal is rarel in*ol*e+ ; utt5ere is still t5e &ossiilit o7 siultaneous in*ol*eent o7

t9o 4anals181820.

Re4entl8 Ga4e21 &ro&ose+ a neural t5eor 7or

$38 in 95i45 t5ere 9as +e%eneration o7 t5e sa44ular %an%lion se4on+ar to a latent *iral rea4ti*ation. ,u45rein7e4tion 4oul+ result in t5e loss o7 its anta%onisti4e77e4t on t5e &osterior sei4ir4ular 4anal. T5is 4oul+lea+ to u&9ar+ *erti4al +isso4iate+ rotator nsta%us8o7 liite+ +uration. ,u45 nsta%us is 4orrelate+ 9it5a4ti*ation o7 t5e &osterior 4anal.

@IAGNO,I,

T5e +ia%nosis o7 $3 is essentiall 4lini4al. T5e4lassi4 4o&laint is *erti%o in e&iso+es8 tri%%ere+ 45an%es in t5e o+ &osition or 5ea+ o*eents8 las"tin%

se4on+s an+ 4easin% s&ontaneousl. T&i4all8 t5e *erti%oarises in t5e lateral &osition o7 one or ot5 si+es8 in5&ere'tension o7 t5e 5ea+8 95en stan+in% u& or lin%

+o9n. <suall t5ere are no au+itor s&tos1!82282.

,oe ot5er s&tos 4oul+ e asso4iate+ an+ o7ten&ersist a7ter t5e interru&tion o7 t5e e&iso+e8 su45 as

nausea8 ialan4e8 or &ostural instailit181!. $esi+es t5e

4lini4al 5istor8 t5e +ia%nosis o7 $3 taes into a44ountt5e t&e8 +ire4tion an+ +uration o7 nsta%us &ro*oe+ aneu*ers t5at &ro*i+e 4lues 7or i+enti7in% t5e



136

a77e4te+ 4anal an+ t5e &at5o&5siolo%i4al e45anis

in*ol*e+ (95et5er 4analit5iasis or 4u&ulolit5iasis).I+enti7in% t5e a77e4te+ 4anal in4lu+es

oser*ation o7 t5e &osition t5at tri%%ers t5e +i//iness



an+ t5e resultin% t&e o7 nsta%us. Ea45 o7 t5esei4ir4ular 4anals is +ire4tl 4onne4te+ to a &air o7 e'trinsi4 us4les in t5e ee8 5a*in% an e'4itator an+in5iitor in7luen4e8 95i45 +eterines t5e o*eent o7

t5e eeall in t5e sae &lane as t5e 4anal2# (Tale 1).

Table 1. Conne4tions et9een sei4ir4ular 4anals an+ ee

us4les.

,E-ICIRC<LAREJCITATION IN?I$ITION

CANAL

I0,ILATERAL -E@IAL CONTRALATERAL

?ORIKONTALRECT<, -E@IAL RECT<,

CONTRALATERAL I0,ILATERAL

LATERAL RECT<, LATERAL RECT<,

I0,ILATERAL I0,ILATERAL

0O,TERIOR,<0ERIOR O$LI<E IN2ERIOR O$LI<E

CONTRALATERAL CONTRALATERAL

IN2ERIOR RECT<, ,<0ERIOR RECT<,

I0,ILATERAL I0,ILATERAL

ANTERIOR,<0ERIOR RECT<, IN2ERIOR RECT<,

CONTRALATERAL CONTRALATERAL

IN2ERIOR O$LI<E ,<0ERIOR O$LI<E

5en t5e &atient %ets in t5e &osition t5attri%%ers t5e +i//iness8 ee o*eent is oser*e+resultin% 7ro t5e 4ontra4tion o7 us4les relate+ to t5ea77e4te+ 4anal (slo9 4o&onent)8 7ollo9e+ suseuent ra&i+ 4or"re4tion in t5e o&&osite +ire4tion(7ast 4o&onent). T5is i&5asi4 o*eent8 4alle+nsta%us8 is a stan+ar+ +ire4tion t5at is no9n asein% t5e sae as t5e 7ast 4o&onent.

In t5e *erti4al 4anals8 t5ere are e'4itator 4onne4"tions to t5e i&silateral su&erior oliue an+ 4ontralateralin7erior re4tus to t5e &osterior 4anal; i&silateral su&erior re4tus an+ 4ontralateral in7erior oliue to t5e su&erior 4anal8 so t5at t5e arisin% o*eents are al9as rotatio"nal8 ut t5e nsta%us is *erti4al u&9ar+ in t5e &osterior

4anal an+ *erti4all +o9n9ar+ in t5e su&erior 4anal2.

T5e 45ara4teri/ation o7 t5e nsta%us8 allo9s t5e

i+enti7i4ation o7 t5e 4anal in*ol*e+ as 9ell as t5e e45a"nis in*ol*e+8 an+ it is essential to 45oose t5e re&osi"

tionin% &ro4e+ure. In Tale 28 9e 4an oser*e t5e ain

7eatures o7 in*ol*eent o7 +i77erent sei4ir4ular 4anals.

@IAGNO,TIC -ANE<3ER,

1.Dix-Hallpike Maneuver

T5e @i'"?all&ie aneu*er is 4onsi+ere+ t5e%ol+ stan+ar+ tool 7or t5e +ia%nosis o7 $3 o7

&osterior 4anal.T5e @i'"?all&ie aneu*er is &er7ore+ t5e

4lini4ian o*in% t5e &atient t5rou%5 a set o7 s&e4i7ie+

5ea+"&ositionin% aneu*ers to eli4it t5e e'&e4te+ 45a"ra4teristi4 nsta%us o7 &osterior 4anal $3 (i%ure1). $e7ore e%innin% t5e aneu*er8 t5e 4lini4ian s5oul+4ounsel t5e &atient re%ar+in% t5e u&4oin%o*eents an+ 9arn t5at t5e a &ro*oe a su++enonset o7 in"tense suBe4ti*e *erti%o8 &ossil 9it5nausea8 95i45 9ill susi+e 9it5in 60 se4on+s. $e4auset5e &atient is %oin% to e &la4e+ in t5e su&ine &ositionrelati*el ui4l 9it5 t5e 5ea+ &osition sli%5tl elo9t5e o+8 t5e &atient s5oul+ e oriente+ so t5at8 in t5esu&ine &osition8 t5e 5ea+ 4an M5an% 9it5 su&&ort o77 t5e &osterior e+%e o7 t5e e'aination tale aout 20

+e%rees. T5e e'ainer s5oul+ ensure t5at 5e 4ansu&&ort t5e &atients 5ea+ an+ %ui+e t5e &atientt5rou%5 t5e aneu*er sa7el an+ se4urel8 9it5out t5e

e'ainer losin% su&&ort or alan4e 5isel7 .



Table 2. 3ariants o7 $3 ina44or+an4e to t5e45ara4teristi4s o7 &ositionin%nsta%us.

CANALIT?IA,I, or

C<0<LOLIT?IA,I,

@<RATION

,TI-<LATE@ -<,CLE CONTRALATERAL IR

3ERTICAL <0AR@

RIG?T

2A,T CO-0ONENT CO<NTER"CLOCPI,E

@IRECTION 3ERTICAL <0AR@

LE2T

N,TAG-<, LATENC

,C"Can &osterior sei4ir4ular

4anal; ,,C"Can: su&erior

sei4ir4ular 4anal; L,C"Can:

lateral sei4ir4ular 4anal. ,O Q

su&erior oliue; I Q in7erior

re4tus; IO Q in7erior oliue; ,R

Q su&erior re4tus; -R Q e+ial

re4tus; LR Q lateral re4tus.





137



Figure 1. osition o7 t5e @i' ?all&ie test to e*aluate t5e le7t

&osterior sei4ir4ular 4anal.

T5e aneu*er e%ins 9it5 t5e &atient in t5e u&ri%5t

seate+ &osition 9it5 t5e e'ainer stan+in% at t5e &atientssi+e. e +es4rie t5e aneu*er to test t5e le7t ear as t5e

sour4e o7 t5e &osterior 4anal $3. T5e e'ainer rotatest5e &atients 5ea+ #! +e%rees to t5e le7t an+8 9it5 anual

su&&ort8 aintains t5e #!"+e%ree 5ea+ turn to t5e le7t

+urin% t5e ne't &art o7 t5e aneu*er . Ne't8 t5e e'ainer

7airl ui4l o*es t5e &atient (95o is instru4te+ to ee&t5e ees o&en) 7ro t5e seate+ to t5e su&ine le7t"ear

+o9n &osition an+ t5en e'ten+s t5e &atients ne4 sli%5tl(a&&ro'iatel 20 +e%rees elo9 t5e 5ori/ontal &lane) so

t5at t5e &atients 45in is &ointe+ sli%5tl u&9ar+8 9it5 t5e5ea+ 5an%in% o77 t5e e+%e o7 t5e e'ainin% tale an+

su&&orte+ t5e e'ainer. T5e e'ainer oser*es t5e&atients ees 7or t5e laten48 +uration8 an+ +ire4tion o7 t5e

nsta%us. A%ain8 t5e &ro*oe+ nsta%us in &osterior 4anal $3 is 4lassi4all +es4rie+ as a i'e+ torsional

an+ *erti4al o*eent 9it5 t5e u&&er &ole o7 t5e ee

eatin% to9ar+ t5e +e&en+ent ear. T5e &atient s5oul+ also

e uerie+ as to t5e &resen4e o7 suBe4ti*e *erti%o.

A7ter resolution o7 t5e suBe4ti*e *erti%o an+ t5ensta%us8 i7 &resent8 t5e &atient a e slo9l returne+to t5e u&ri%5t &osition. @urin% t5e return to t5e u&ri%5t&osition8 a re*ersal o7 t5e nsta%us a e oser*e+

an+ s5oul+ e allo9e+ to resol*e. T5e @i'"?all&ie a"

neu*er s5oul+ t5en e re&eate+ 7or t5e ri%5t si+e8 9it5 t5eri%5t ear arri*in% at t5e +e&en+ent &osition. A%ain8 t5ee'ainer s5oul+ inuire aout suBe4ti*e *erti%o an+i+enti7 oBe4ti*e nsta%us8 95en &resent. T5e

e'aination o7 t5e ri%5t si+e 4o&letes t5e test.

T5e &arti4les &resent insi+e t5e sei4ir4ular 4anal un+er%o t5e e77e4ts o7 %ra*it an+ are s5i7te++o9n9ar+8 an+ a7ter a s5ort laten48 t5e lieratin% 7or4e4reate+ on t5e a&ullar 4rista tri%%ers t5e *erti%o an+nsta%us (i%ure 2).

In t5e 4ase o7 t5e su&erior sei4ir4ular 4anal8 a

torsional +o9neatin% nsta%us is e'5iite+. T5e

+ire4tion o7 t5e torsional 4o&onent o7 t5e &ositionin%

nsta%us in+i4ates 95i45 ear is t5e ori%in o7 nsta%us.

I7 t5e u&&er &ole o7 t5e ee eats a9a 7ro t5e %roun+

Figure 2. -e45anis o7 +is&la4eent o7 t5e +eris 7ro t5e +oe o7

t5e 4anal at rest an+ un+er t5e a4tion o7 %ra*it (%)8 in+i4ate+ t5e

arro9. (a) an+ () Q 4u&ulolit5iasis; (4) an+ (+) Q 4analit5iasis.

to9ar+ t5e u&&erost ear8 t5en it ori%inates 7ro t5eanterior 4anal o7 t5e u&&erost ear. I7 it eats to9ar+t5e %roun+ t5en it ori%inates 7ro t5e un+erost ear.

2. Supine Head oll Tes!

I7 t5e &atient 5as a 5istor 4o&atile 9it5 $3an+ t5e @i'"?all&ie test is ne%ati*e8 t5e 4lini4ians5oul+ &er7or a su&ine roll test to assess 7or lateral

sei4ir4ular 4anal $3

.Lateral 4anal $3 (also 4alle+ 5ori/ontal 4anal$3) is t5e se4on+ ost 4oon t&e o7 $3. $e"4ause t5is t&e o7 $3 5as re4ei*e+ 4onsi+eral lessattention in t5e literature8 4lini4ians a e relati*eluna9are o7 its e'isten4e an+ t5e a&&ro&riate +ia%nosti4

aneu*ers 7or lateral 4anal $3. atients 9it5 a 5istor

4o&atile 9it5 $3 (ie8 re&eate+ e&iso+es o7 *erti%o&ro+u4e+ 45an%es in 5ea+ &osition relati*e to %ra*it)95o +o not eet +ia%nosti4 4riteria 7or &osterior 4anal$3 s5oul+ e in*esti%ate+ 7or lateral 4anal $3.

In an instan4es8 t5e &resentin% s&tos o7

lateral 4anal $3 are in+istin%uis5ale 7ro &osterior

4anal $3. T5e su&ine roll test is &er7ore+ initiall&ositionin% t5e &atient su&ine 9it5 t5e 5ea+ in neutral

&osition8 7ollo9e+ ui4l rotatin% t5e 5ea+ 0 +e%re"es

to one si+e 9it5 t5e 4lini4ian oser*in% t5e &atients ees

7or nsta%us. A7ter t5e nsta%us susi+es (or i7 no

nsta%us is eli4ite+)8 t5e 5ea+ is t5en returne+ to t5e

strai%5t 7a4e"u& su&ine &osition. A7ter an a++itional

eli4ite+ nsta%us 5as susi+e+8 t5e 5ea+ is t5en ui4l







138



turne+ 0 +e%rees to t5e o&&osite si+e8 an+ t5e eesare on4e a%ain oser*e+ 7or nsta%us. T9o &otentialns"ta%us 7in+in%s a o44ur 9it5 t5is aneu*er8

re7le4tin% t9o t&es o7 lateral 4anal.T5e +ire4tion o7 nsta%us is +e7ine+ t5e 7or

o7 t5e +isease. In 4analit5iasis8 t5e o*eent o7 t5e 5ea+to9ar+ t5e a77e4te+ ear &rootes t5e +is&la4eent o7 7ree&arti4les in t5e +ire4tion o7 t5e a&ulla8 tri%%erin% a

5ori/ontal nsta%us 95ose 7ast 4o&onent 9ill eto9ar+ t5e teste+ ear8 so %eotro&i4 (to9ar+s t5e %roun+).5en t5e 5ea+ is rotate+ to t5e 5ealt5 si+e8 t5e &arti4les+is&la4e an+ lea+ to a 4urrent o*in% in t5e o&&osite+ire4tion 7ro t5e a&ulla (also %eneratin% %eotro&i4nsta%us)8 an+ t5e stiulation is less intense t5an t5atoser*e+ on t5e a77e4te+ si+e. T5us8 t5e resultin% eeo*eent is al9as stron%er 95en t5e a77e4te+ ear is

&la4e+ +o9n9ar+2. In 4u&ulolit5iasis8 t5e 7ra%ents are

a+5ere+ to t5e 4u&ulae o7 t5e a77e4te+ sei4ir4ular 4anal895i45 ae t5e 5ea*ier t5an t5e en+ol&5. 5en t5e5ea+ is rotate+ to one si+e8 t5e a4tion o7 %ra*it on t5ea&ullar 4rista o*es t5e +eris into t5e o&&osite

+ire4tion an+ it is &ossile to oser*e t5e nsta%us t5atis in t5e o&&osite +ire4tion 7ro t5e teste+ ear (a&o%e"

otro&i4 t&e)2#82!.

T5e %eotro&i4 7or is &re+oinant. T5e e"45aniss t5at initiate %eotro&i4 an+ a&o%eotro&i4 eeo*eents 4an e seen in i%ure .

Figure ". e 4an oser*e t5e e45anis o7 +is&la4eent o7 t5e

a"&ullar 4rista t5at is res&onsile 7or t5e ori%in o7 %eotro&i4

nsta%us in 4analit5iasis(a)8 or 7or a&o%eotro&i4 nsta%us in

4u&ulolit5iasis (). 1 " a&ullar 4rista8 2 " 7ra%ents o7 otolit5s. T5e

arro9s in+i4ate t5e +ire4tion o7 +is&la4eent o7 t5e 4u&ulae

%ra*it 9it5 t5e laterali/ation o*eent o7 t5e 5ea+.

@ue to an a+a&tation o7 t5e 4entral ner*ous ss"

te826 or to t5e re*ersion o7 t5e +ire4tion o7 o*eent o7

t5e +eris t5e %ra*itational a4tion268 it is not unusualt5at nsta%us s&ontaneousl 45an%es t5e +ire4tion

9it5out t5e 5ea+ turnin% to t5e o&&osite si+e826. @e la

-eilleure et al.26 re&orte+ t5e in*ersion o7 t5e 5ori/ontalnsta%us8 in ele4tronsta%o%ra&58 in ! o7 &atients9it5 $3 o7 t5e lateral 4anal8 al9as on t5e a77e4te+

si+e. Lee an+ 4ollea%ues2 +es4rie+ t5e s&ontaneous

re*ersal o7 nsta%us ilaterall8 an+ t5e &riar &5ase o7 nsta%us 9as s5orter an+ 9it5 %reater *elo4it o7 t5eslo9"&5ase.

ETIOLOGICAL @IAGNO,I,

$3 is i+io&at5i4 or se4on+ar to ot5er 4lini4al4on+itions8 i.e.: 5ea+ traua ( to 1)8 *estiular neu"

ritis (u& to 1!)8 -enieres +isease (0.! to 1)28280.

$oa%lio et al.1 re&orte+ t5e $3 in 6 o7 &atients 9it5-enieres +isease. Ot5er &ossile 4auses are o*arian5oronal +s7un4tion8 5&erli&i+eia8 5&o%l4eia or

5&er%l4eia8 5&erinsulineia8 i%raine8 4er*i4altraua8 otolo%i4al sur%er8 se+entar an+ &rolon%e+

e+ rest281!8288#.

A@@ITIONAL EA-,

A++itional e'as are essential to 4lari7 t5e

tri%%er an+ asso4iate+ 7eatures o7 $3181!8 28!.

1. adiograp#i$ i%aging

Ia%in% is not use7ul in t5e routine +ia%nosis o7 $3 e4ause t5ere are no ra+iolo%i4al 7in+in%s

45ara4teristi4 o7 or +ia%nosti4 7or $3. urt5er ra"

+io%ra&5i4 ia%in% a &la a role in +ia%nosis i7 t5e4lini4al &resentation is 7elt to e at&i4al8 i7 t5e+ia%nosti4 aneu*ers are unusual8 or i7 a++itionals&tos asi+e 7ro t5ose attriutale to $3 are&resent8 su%%estin% an a44o&anin% o+i7in%

4entral ner*ous sste or otolo%i4al +isor+ers.

2. &es!ibular !es!ing

Ele4tronsto%ra&5 5as liite+ utilit in t5e*erti"4al 4anal $3 +ia%nosis8 sin4e t5e torsional4o&onent o7 nsta%us 4annot e re%istere+ 4on*entional te"45niues. On t5e ot5er 5an+ in5ori/ontal sei4ir4ular 4anal $3 +ia%nosis8 t5e

nsta%us is &resent in t5e &ositional testin%2.T5e *estiular test atter is ale to e*i+en4e as"

so4iate+ anoralities8 relati*el 4oon in $38 ut

nons&e4i7i410868 i.e.: *estiular 5&o7un4tion (! o7 t5e

$3 4ases). <nilateral *estiular 5&o7un4tion 4oul+ or

not e asso4iate+ to t5e a77e4te+ si+e. T5us8 it is not a

&ro%nosti4 7eature o7 re4urren4e20. It 5as een &ro&ose+

Porres22 t5at t5e unilateral *estiular 5&o7un4tion is







139



ore 4oon in 4ases se4on+ar to 5ea+ traua or *iral in7e4tion.

". 'udio%e!ri$ Tes!ing

Au+ioetr is not reuire+ 7or +ia%nosin% $38

5o9e*er it a o77er a++itional in7oration in 4ases

95ere t5e 4lini4al +ia%nosis o7 *erti%o is un4lear .

@IERENTIAL @IAGNO,I,

ositional *erti%o an+ nsta%us 4oul+ e as"

so4iate+ 9it5 +isor+ers in t5e 4entral ner*ous sste8

i.e.: neuro*as4ular 4o&ression o7 4ranial ner*e 3III8

*estiular s459annoa8 Arnol+"C5iari al7oration

an+ a *ariet o7 4ereellar +isor+ers.

TREAT-ENT

T5e treatent o7 $3 is ase+ on t5e &er7or"an4e o7 lierator aneu*ers or 4analit5re&ositionin% &ro4e+ures8 9it5 t5e ai o7 returnin% t5e+is&la4e+ &ar"ti4les to t5eir ori%inal lo4ation: utri4ular a4ula. T5ese are non"in*asi*e &ro4e+ures t5at 5a*e

een 7oun+ to e lon% ter e77e4ti*e 7or $3281#. A stan+ar+ &roto4ol8 t5at is +es4rie+ in Tale 8

is use+ in our ser*i4e8 4onsi+erin% t5e etter results 7or ea45 aneu*er in+i4ate+ 7or ea45 $3 *ariant. T5ereare ot5ers aneu*ers +es4rie+ in t5e literature8in+i4a"te+ to ea45 $3 *ariant. ,u44ess7ul treatent+e&en+s ainl on t5e 45oi4e o7 t5e ost a&&ro&riateaneu*er 7or t5e 4ase.

Table ". -aneu*er a44or+in% ea45 $3 *ariantD181#82F.

3ARIANT $3

LET ,C"Can CANALIT?IA,I,

LET ,C"Can C<<LOLIT?IA,I,

RIG?T ,C"Can CANALIT?IA,I,

RIG?T ,C"Can

C<<LOLIT?IA,I,

LET ,,C"Can CANALIT?IA,I,

LET ,,C"Can C<<LOLIT?IA,I,

RIG?T ,,C"Can CANALIT?IA,I,

RIG?T ,,C"Can

C<<LOLIT?IA,I,

LET L,C"Can CANALIT?IA,I, OR

C<<LOLIT?IA,I,

RIG?T CANALIT?IA,I, OR

C<<LOLIT?IA,I,

,C"Can: &osterior sei4ir4ular

4anal; ,,C"Can: su&erior

sei4ir4ular 4anal; L,C"Can: lateral

sei4ir4ular 4anal.

,oe &atients ani7est se*ere s&tos 9it5+i//iness8 nausea8 s9eatin% an+ *oitin% 95ile un+er"%oin% +ia%nosti4 or t5era&euti4 aneu*ers. In t5ese4ases8 *estiular su&&ressant e+i4ations are re4o"en+e+ as a+Bun4ts not onl to relie*e t5e *erti%o a7ter aneu*er ut also to 4ontrol t5e 4lini4al s&tos until

t5e &ro4e+ure 4an e re&eate+#. T5era&euti44ate%ories in4lu+e e4li/ine8 +ien5+rinate84lona/e&a8 +ia"/e&a. @osa%e a *ar in 7un4tion

o7 t5e intensit o7 s&tos. ,oe aut5ors &re7er to9ait 7or t5e natural 4ourse to9ar+s a s&ontaneousrelie78 4onsi+erin% $3 a sel7"liite+ 4on+ition.

Clini4al reission 4an o44ur in t5ree to 7our 9ees8.

1. (pley Maneuver

T5e E&le aneu*er is t5e ost 7reuentl &er"

7ore+ re&ositionin% aneu*er o7 t5e *erti4al 4anal. T5e&atient is &la4e+ in t5e u&ri%5t &osition 9it5 t5e 5ea+turne+ #! +e%rees to le7t 95en t5e le7t ear is a77e4te+. T5e&atient is ra&i+l lai+ a4 in a su&ine 5ea+"5an%in%&osition8 95i45 is aintaine+ 7or a &erio+ o7 1 to 2 i"nutes. Ne't8 t5e 5ea+ is turne+ 0 +e%rees8 to t5e ri%5t(usuall ne4essitatin% t5e &atients o+ to o*e 7rosu&ine &osition to t5e lateral +e4uitus &osition). T5us8 t5e&atients 5ea+ is nearl in t5e 7a4e+o9n &osition. T5is&osition is 5el+ 7or 0 to 60 se4on+s. T5en t5e &atient isase+ to rest t5e 45in on t5e s5oul+er an+ sit u& slo9l8

4o&letin% t5e aneu*er (i%ure #). T5e 5ea+ ust sta

in t5at &osition 7or soe oents8 e7ore it returns to t5e

noral &osition18#828#0. i%ure ! +eonstrates t5e

&ro4e+ure.

Figure ). E&le -aneu*er 7or ri%5t"si+e+ &osterior sei4ir4ular 4anal

$3.

A44or+in% to t5e 4lini4al &ra4ti4e %ui+eline8ase+ on t5e re*ie9 o7 t5e literature8 it 9as not&ossile to +eter"ine t5e o&tial nuer o7 44les 7or t5e re&ositionin% aneu*ers.

Le&ert to9ar+ t5e le7t ear

-ANE<3ER

E&le e%innin% on t5e le7t

,eont to9ar+ t5e le7t

?ea+ turne+ to t5e ri%5t

E&le e%innin% on t5e ri%5t

,eont to9ar+ t5e ri%5t

?ea+ turne+ to t5e le7t

E&le e%innin% on t5e le7t

,eont to9ar+ t5e le7t

?ea+ turne+ to t5e le7t

E&le e%innin% on t5e ri%5t

,eont to9ar+ t5e ri%5t

?ea+ turne+ to9ar+ ri%5t

Le&ert to9ar+ t5e ri%5t ear







140



Figure *. ,eont -aneu*er 7or treatent o7 ri%5t"si+e+ &osterior

sei4ir4ular 4anal 4u&ulolit5iasis.

2. Se%on! Maneuver +libera!ory %aneuver,

T5e aneu*er +es4rie+ ,eont#1 is in+i4ate+

7or t5e treatent o7 &osterior 4anal 4u&ulolit5iasis. I7 t5e&osterior 4anal is a77e4te+8 t5e &atient is seate+ in t5eu&ri%5t &osition; t5en t5e &atients 5ea+ is turne+ #!+e%rees to9ar+ t5e una77e4te+ si+e8 an+ t5en is ra&i+lo*e+ to t5e si+e"lin% &osition. Nsta%us an+ *erti%oa e oser*e+. T5is &osition is 5el+ 7or 1 to inutes.T5e &atient is ra&i+l o*e+ to t5e o&&osite si+e"lin%&osition 9it5out &ausin% in t5e sittin% &osition an+ 9i"t5out45an%in% t5e 5ea+ &osition relati*e to t5e s5oul+er.Gra+uall t5e &atient resues t5e u&ri%5t sittin% &osi"

tion. I7 t5e su&erior sei4ir4ular 4anal is a77e4te+8 t5e

o*eent is &er7ore+ in t5e +ire4tion o&&osite to t5e

&ro4e+ure 7or &osterior sei4ir4ular 4anal#81!828#0. i%ure 6

+eonstrates t5e ,eont -aneu*er 7or treatent o7 ri%5t"si+e+ &osterior sei4ir4ular 4anal 4u&ulolit5iasis.

". e%per! Maneuver

Le&ert#2 +es4rie+ a aneu*er ($are4ue -a"neu*er or Roll -aneu*er) 95i45 is t5e ost 4oonle&loe+ aneu*er 7or t5e treatent o7 lateral 4anal$3. T5is aneu*er in*ol*es rollin% t5e &atient 60+e%rees in a series o7 ste&s to e77e4t &arti4le re&osi"

tionin%. T5e &atient is in su&ine &osition; t5e &atients

5ea+ is turne+ 0 +e%rees slo9l to9ar+ t5e una77e4te+si+e. T5e 5ea+ is 5el+ in t5is &osition8 an+ t5e o+ isturne+ to lateral +e4uitus. T5en8 t5e 5ea+ is turne+ to t5e7a4e+o9n &osition an+ t5e o+ is o*e+ to t5e *entral+e4uitus. Later t5e &atients 5ea+ is turne+ 0 +e%rees8an+ t5e o+ is &la4e+ on lateral +e4uitus. Gra+uall8 t5e&atient resues t5e su&ine &osition. Ea45 ste& isaintaine+ 7or 1! se4on+s Q 7or slo9 i%ration o7 t5e&arti4les8 in res&onse to %ra*it. To 4o&lete t5eaneu*er8 t5e &atient is rou%5t into t5e u&ri%5t sittin%

&osition 9it5 5ea+ o9e+ +o9n at 0 +e%rees28#8##. T5e

aneu*er seuen4e is re&resente+ in i%ure .

). For$ed prolonged posi!ion

or4e+ &rolon%e+ &osition is anot5er treatent

Figure . @eonstration o7 Le&ert -aneu*er seuen4e Q treatent

o7 lateral sei4ir4ular 4anal $3 (ri%5t ear in la4).

Figure /. $ran+t"@aro77 e'er4ises 7or 5oe sel7"a+inistration treat"

ent.

aneu*er8 +es4rie+ 3annu45i##8 7or t5e treatent

o7 lateral 4anal $3. T5e strate% 4onsists o7 aintainin% t5e 7or4e+ lateral +e4uitus8 9it5 a77e4te+

ear in t5e un"+erost &osition 7or 12 5ours282!.

*. 0rand!-Daro exer$ises

T5e $ran+t"@aro77 e'er4ises 9ere +e*elo&e+ 7or 5oe sel7"a+inistration8 as an a++itional t5era& 7or &atients 95o 5a*e een s&toati48 e*en a7ter E&leor ,eont aneu*er #0. ,oe aut5ors in+i4ate t5eone 9ee e7ore t5e t5era&euti4 aneu*er8 aiin% to

i&ro*e t5e &atients tolerailit1#

. T5e $ran+t"@aro77 e'er4ises (i%ure ) are &ositionin% e'er4ises t5at8t5eoreti4all8 &roote 5aituation#.

T5e in*ol*eent o7 ore t5an one sei4ir4ular

4anal is not unusual. In t5ese 4ases8 t5e re&ositionin%

aneu*er 9ill e a&&lie+ in ste&s. T5e treatent o7 ea45

a77e4te+ sei4ir4ular 4anal 9ill e &er7ore+8 in &roto4ols

a44or+in% to t5e oser*e+ o4ular o*eents an+ t5e







141



Figure . Canalit5 Ja " ne%ati*e &ressure in t5e sei4ir4ular 4anal

4u&ulae. @otte+ line e*i+en4es t5e ori%inal &osition 4u&ulae.

4orre4t i+enti7i4ation o7 ea45 a77e4te+ sei4ir4ular 4anal.

-an &atients 4o&lain o7 ialan4e +urin% an+ et9een*erti%o atta4s8 as oser*e+ eleiso#!. T5isoser*ation lea+ to t5e in*esti%ation o7 &ostural alan4e in

&atients 9it5 lateral an+ &osterior sei4ir4ular 4anal$3. atients 9it5 &osterior $3 5a+ i&aire+ stati4

alan4e ailit 95en *isual an+ &ro&rio4e&ti*e in&uts 9ere

ina+euate as +es4rie+ eleiso#!8 @i

Girolao#6.T5e otolit5i4 +s7un4tion in+u4e+ uneual

loa+s o7 t5e a4ular e+s 5as een 4onsi+ere+ as t5e

un+erlin% e45anis#6. Ot5er &ossiilities are t5e&ersisten4 o7 sall aounts o7 resi+ual +eris in t5e4anal8 &aresis o7 t5e a&ullar re4e&tors or t5e

*estiular re"a+a&tation a7ter &eri&5eral +isor+er #!.

CO-LICATION, O -ANE<3ER,

T5e re&ositionin% aneu*ers are asso4iate+ toil+ an+ sel7"liite+ a+*erse e77e4ts in aout 12 &er4ent

o7 t5e treate+ &atients. T5e ost 4oonl en4oun"tere+

4o&li4ations in4lu+e nausea an+ *oitin%. T5e

4on*ersion to lateral 4anal $3 (so 4alle+ 4anal s9it45)

an+ Canalit5 Ja are unusual 4on+itions8 5o9e*er 95en

&resent ust e &ro&tl +ia%nose+ an+ treate+#.

1. 3anal swi!$#@urin% t5e 4ourse o7 re&ositionin% aneu*ers o7

*erti4al 4anals8 t5e +is&la4e+ &arti4les 4oul+ i%rate into

t5e lateral 4anal8 in 6 to o7 t5e 4ases. In t5ese 4ases8

t5e torsional nsta%us e4oes 5ori/ontal an+

%eotro&i4#8#8#. T5e treatent is Le&ert -aneu*er #.

2. 3anali!# 4a%

@urin% t5e re&ositionin% aneu*ers8 soe&atients +e*elo& se*ere8 &ersistent *erti%o8 nausea8*oitin% an+ nsta%us8 95i45 5as t5e sae 7eaturesoser*e+ in t5e +ia%nosti4 aneu*ers. T5is &5enoe"non 4oul+ result 7ro a Bain% o7 t5e otolit5i4 +eris(nae+ Ba) 95en i%ratin% 7ro a 9i+er to narro9er se%ent8 su45 as 7ro t5e a&ulla to t5e 4anal or at

t5e i7ur4ation o7 t5e 4oo 4rus!0. In t5e E&le

-aneu"*er8 it 5a&&ens 95en t5e 5ea+ o7 t5e &atient isturne+ to 7a4e+o9n &osition (i%ure ! Q &osition 4 an++). T5e Ba %enerates a 4onstant 4ounter"attra4tion7or4e in t5e 4u&ulae8 as result 7ro ne%ati*e &ressure.T5e Ba &ressure in+u4es 4u&ulae +is&la4eent an+4onseuent +e&olari/ation (*erti4al 4anals) or 5&er&olari/ation (late"ral 4anals). T5e nsta%us+oes not 45an%e 9it5 5ea+ &osition o*eent.

T5e treatent 4onsists o7 &er7oran4e o7 t5e re"*erse aneu*er8 to ai to eliinate t5e lo4a+e.

T5us8 t5e 4rista returns to t5e rest &osition 18#8#. I7 t5e&atient +e*elo&s i&ortant s&tos8 *estiular su&&ressant e+i4ations a e 4onsi+ere+ to 5el& in

a later re&osi"tionin%. T5e 4analit5 Ba in4i+en4e8+urin% re&ositionin% aneu*ers8 is aout 2.

$ *irtue o7 &ossile 4o&li4ations +urin% t5ere&ositionin% &ro4e+ures8 it is not a &ro&er 4on+u4t to%ui+e t5e &atient sel7"treatent at 5oe8 9it5out a&5si4ian.

O,TREAT-ENT RE,TRICTION,

A7ter re&ositionin% &ro4e+ures8 it is i&ortant toee& t5e &atient in sittin% &osition8 7or 10 inutes8 to a*oi+

7alls!1. T5e use o7 a 4er*i4al 4ollar8 &ositional a*oi+an4e8

or ot5er restri4tions are not ne4essar!28!8!#. 3estiular

su&&ressant e+i4ations 4oul+ e use7ul.E&le8 in 5is ori%inal &a&er8 +es4rie+ t5e a&&li"

4ation o7 a one 4on+u4tion *irator asso4iate+ to re"

&ositionin% aneu*er8 in or+er to release soe a+5ere+

&arti4les in t5e a&ullar 4rista. ?o9e*er8 stu+ies 7oun+ no

ene7it in t5e $3 treatent8 sin4e it +oes not o+i7 t5e

results o7 re&ositionin% or lierator aneu*ers28!!8!68!.



International Tinnitus Journal8 3ol. 168 No2 (2011)


142

-ANE<3ER, ROGNO,I,

T5e e77e4ti*eness o7 re&ositionin% an+ lieratoraneu*ers *aries 7ro 0 to 1001#81!828#. T5e su4"4ess7ul treatent is ase+ on t5e i+enti7i4ation o7 t5e

a77e4te+ sei4ir4ular 4anal8 t5e +istin4tion et9een4u&u"lolit5iasis an+ 4analit5iasis8 t5e ri%5t 45oi4e o7 t5eost in+i4ate+ aneu*er 2. T5e s&tos re4urren4e8a7ter 4o&lete reission8 *aries 7ro # to 2 88#.ossile e'&lanations in4lu+e soe 4oori+ities an+&atient liitations +urin% t5e aneu*ers (7or e'a&le:liite+ 4er*i4al ran%e o7 otion or *as4ular 7ailure)1#.Generall8 a ne9 &ro4e+ure lea+s to s&tos relie7 #.In lon%"ter8 re4urren4e a7ter Le&ert an+ E&leaneu*ers8 in ten ears8 is aout 12.

It is i&ortant to e 4are7ul 95en &er7orin%+ia%"nosti48 re&ositionin% an+ lierator aneu*ers inoese &atients8 9it5 liite+ 4er*i4al ran%e o7 otion or

9it5 unstale 5eart 7ailure or 4aroti+ stenois82!8!.,oe aut5ors elie*e in natural 4ourse o7 $3

to9ar+ s&ontaneous relie7 #8!8608618628 95i45 is &ossilein u& to o7 t5e &atients in t5e 7irst ont58 9it5suse"uent re4urren4e in u& to 8 in t5ree

ears8. T5e s&ontaneous resolution is 7aster in t5elateral sei4ir4ular 4anal $3 t5an in &osterior 4anale4ause t5e 7orer s&atial an+ anatoi4 orientation7a4ilitates t5e return o7 t5e &arti4les to t5eir ori%inal

&la4e686#. T5ere7ore8 it is &ossile to &ro&ose to t5e&atient to 9ait t5e s&onta"neous resolution8 in 4ases95ere t5e aneu*er 4ant e in+i4ate+.

$3 -ONITORING

T5irt to !0 o7 t5e &atients 5a*e *estiular ss"te +s7un4tion asso4iate+ 9it5 initiall treate+$38 95i45 4an e +eonstrate+ 4alori4 testin%anora"lities. T5ere7ore8 e*en i7 s&tos are t&i4alo7 $38 t5e +ia%nosti4 aneu*er 5as een &ositi*e8t5e re&osi"tionin% aneu*er 5as een su44ess7ul8 it isi&ortant t5at 4o&lete neurotolo%i4al e*aluation isotaine+ to rule out ot5er *estiular +isor+ers.

In re4urren4e or 7aile+ 4ases8 it a e 4onsi+er t5at 4entral +isor+ers are &ossile 4auses o7 *erti%o8

&arti4ularl t5ose asso4iate+ to 4ereellar *eris or rain ste8 i.e.: 4ereellar +e%eneration8 Arnol+"C5iari

al7oration an+ 7ourt5 *entri4ule roo7 lesions6!.T5ese anoralities s5oul+ &resent nsta%us 9it57eatures D2866F liste+ in Tale #.

CONCL<,ION

$3 is a 4oon sn+roe in 4lini4al &ra4ti4e.

or t5e t5era&euti4 aneu*ers8 4orre4t +ia%nosis o7 t5e

$3 *ariant an+ a77e4te+ sei4ir4ular 4anal is ne4essa"

r. T5ese aneu*ers &ro*i+e a ui4 relie7 7or &atients.

Table ). eatures o7 &ositional nsta%us 9it5 4entral ori%in.

N,TAG-<, IT?O<T LATENC

ETEN@E@ @<RATION8 GENERALL -ORE T?AN 60

,ECON@, @ON OR <$EATING

N,TAG-<, NOT A,,OCIATE@ TO ,TI-<LATE@CANAL N,TAG-<, IT?O<T ATIGA$ILIT

N,TAG-<, IT? INCREA,E@ AN@ @ECREA,E@

INTEN,IT C?ANGE O @IRECTION

NA<,EA AN@ 3O-ITNG NOT A,,OCIATE@ TO

N,TAG-<, AN@ 3ERTIGO INTEN,IT

CERE$ELLAR AN@ OC<LO-OTOR IN@ING,

A 4o&lete neurotolo%i4al e*aluation is i&ortant torule out 4on4oitant +isor+ers. Central etiolo%ies uste in*esti%ate+ 95en at&i4al nsta%us is 7oun+ an+t5era&euti4 aneu*ers are unsu4ess7ull.

$I$LIOGRA

1.arnes L,8 A%ra9al ,P8 Atlas J. @ia%nosis an+ ana%e"ent o7

eni%n &aro'sal &ositional *erti%o ($3). C-AJ200;16():61".

2.roo&ais E8 C5iona T8 Tsa%ournias -8 C5risto+oulou 8

?irs45 $E8 La45anas 3A8 et al. $eni%n &aro'sal &ositional*erti%o: 10 ear e'&erien4e in treatin% !2 &atients 9it5 4analit5re&ositionin% &ro4e+ure. Larn%os4o&e 200!;11!:166"1.

3.C5oun% 8 ,5in R8 Pa5n% ?8 ar Pee5u8 C5oi ,J. S$o9 an+

lean test to +eterine t5e a77e4te+ ear o7 5ori/ontal 4anal eni%n&aro'sal &ositional *erti%o. Larn%os4o&e 2006;116:16"1.

4.Poellier 8 ,uers R8 ?a9ins $. $eni%n &aro'sal

&ositional *erti%o: +ia%nosis an+ treatent in t5e eer%en4+e&artent. A re*ie9 o7 t5e literature an+ +is4ussion o7 4analit5"re&ositionin% aneu*ers. Ann Eer% -e+ 2001;(#):2".

5.-i/uos5i P8 atanae 8 ,5oBau ?8 Ouo J8 atanae I. E&i"

+eiolo%i4al stu+ies on eni%n &aro'sal &ositional *erti%o inJa&an. A4ta Otolarn%ol ,u&&l 1;##:6"2.

6.-ar4elli 38 ia//a 8 isani 8 -ar4iano E. Neuro"otolo%i4al 7eatures

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,8 C5alian AA8 @eson+ AL8 Earll J-8 i7e T@8 uller @C8 Ju+%e JO8-ann NR8 Rosen7el+ R-8 ,45urin% LT8 ,teiner R8 5itne ,L8

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12. ,45une45t ?. Cu&ulolit5iasis. Ar45 Otolarn%ol 16;0:11"

26.

13. *on $re*ern -8 Clare A?8 Le&ert T. Continuous *erti%o

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14. ,teenerson RL8 Cronin G8 -ara45 -. E77e4ti*eness o7



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15. Porres ,8 $alatsouras @8 a&ouliaos ,8 erei+is ,E.

$eni%n &aro'sal &ositional *erti%o an+ its ana%eent. -e+,4i -onit. 200;1(6):CR2!"2.

16. @e La -eillure G8 @e5aene I8 @e&on+t -8 @aan 8

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17. ?er+an ,J8 Tusa RJ. Co&li4ations o7 t5e re&ositionin%

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18. ,u/ui -8 ua9a P8 ?ori%u45i ,8 I45iura A8 Pitaura P8

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19. Iai T8 Noriai T8 Ito -8 Naaae P8 ,aae ?8 uBioa8 et

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Au+iol Neurotol. 2006;11:1"20!.

20. -olina -I8 L&e/"Es4Ue/ JA8 Ka&ata C8 3er%ara L.

-onitorin% o7 4alori4 res&onse an+ out4oe in &atients 9it5eni%n &aro'sal &ositional *erti%o. Otol Neurotol. 200;2:"00.

21. Ga4e RR. at5olo% o7 eni%n &aro'sal &ositional

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22. Porres ,8 $alatsouras @G8 Paeros A8 E4onoou C8

Pan+iloros @8 ere+iis E. O44uren4e o7 sei4ir4ular 4anal

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2002;2:26"2.

23. Porres ,G8 $alatsouras @G. @ia%nosti48 &at5o&5siolo%i48

an+ t5era&euti4 as&e4ts o7 eni%n &aro'sal &ositional *erti%o.Oto"larn%ol ?ea+ an+ Ne4 ,ur%. 200#;11:#"##.

24. ?onruia 38 $alo5 R8 ?arris -R8 Ja4oson P-.

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25. C5iou 8 Lee ?8 Tsai ,8 ?sue5 8 Lee . A sin%le t5era&

7or all sut&es o7 5ori/ontal 4anal &ositional *erti%o.Larn%os4o&e 200!;11!:1#2"!.

26. @e la -eileure G8 @e5aene I8 @e&on+t -8 @aa 8 Cre*its

L8 3an5ooren G. $eni%n &aro'sal &ositional *erti%o o7 t5e

5ori/ontal 4anal. J Neurol Neurosur% s45iar. 16 Jan;60(1):6"

1.

27. Lee ,?8 Pi -P8 C5o P?8 Pi J,. Re*ersal o7 initial

&ositionin% nsta%us in eni%n &aro'sal &ositional *erti%oin*ol*in% t5e 5ori/ontal 4anal. Ann N A4a+ ,4i. 200-a;116#:#06".

28. Gross E-8 Ress $@8 3iirre E,8 Nelson JR8 ?arris J.

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29. Paler% -8 ?all P8 ui4ert N8 ?inson J8 ?ala% G-.

5at inner ear +iseases 4ause eni%n &aro'sal &ositional*erti%oX A4ta Otolarn%o. 2000;120:0"!.

30. ?u%5es CA8 ro4tor L. $eni%n &aro'sal &ositional

*erti%o. La"rn%os4o&e 1;10:60"1.

31. $oa%lio -8 ,oares LCA8 Ira5i C,-N8 GananYa 8 Cru/

OL-. @oenYa +e -VniWre e *erti%e &ostural. $ra/ JOtor5inolarn%ol.. 200;6(1);6"2.

32. Gia4oini G8 Na&olitano $8 Alessan+rini -8 @i Girilao

,8 -a%rini A. Re4urrent &aro'sal &ositional *erti%o relate+ tooral 4ontra"4e&ti*e treatent. Gne4ol En+o4rinol. 2006;22(1):!".

33. @orn5o77er JL8 Mi Col*in G$. $eni%n &aro'sal

&ositional *erti%o an+ 4analit5 re&ositionin%: 4lini4al 4orrelations. A J Otol. 2000;21:20".

34. Jan% ,8 ?9an% C?8 ,5in J8 $ae 8 Pi L,. A%e"

relate+ 45an%es on t5e or&5olo% o7 t5e oto4onia.Larn%os4o&e. 2006;116:6"1001.

35. Patsaras A. aro'sal &ositional *erti%o: an o*er*ie9

an+ t5e +e&osits re&ositionin% aneu*er. A J Otol.1!;16(6):2!"0.

36. Patsaras A. Eletronta%o%ra&5i4 (ENG) 7in+in%s in

&aro'sal &ositional *erti%o (3) as a si%n o7 *estiular +s7un4tion. A4ta Otolarn%ol8 11;111:1"200.

37. $lael $. A ran+oi/e+8 4ontrolle+ assessent o7 t5e

4a"nalit5 re&ositionin% aneu*er. Otolarn%ol ?ea+ Ne4 ,ur%.1#;110:1"6.



38. Assa9a*i45ian%in+a ,8 Isi&ra+it 8 ,ni+*on% P8

,u&ia&5un . Canalit5 re&ositionin% 7or eni%n &aro'sal&ositional *erti%o: a ran+oi/e+ 4ontrolle+ trial. Ear Nose T5roatJ. 2000;0:2".

39. E&le J. T5e 4analit5 re&ositionin% &ro4e+ure 7or treatent

o7 e"ni%n &aro'sal &ositional *erti%o. Otolarn%ol ?ea+ Ne4,ur%. 12;10:"#0#.

40. $ran+t T8 ,te++in ,8 En% @. T5era& 7or eni%n

&aro'sal &osi"tionin% *erti%o8 re*isite+. Neurolo%.1#;##:6"00.

41. ,eont A8 ress E8 3itte . Curin% t5e $3 9it5 a

lierator aneu*er. A+* Otor5inolarn%ol. 1;#:20".

42. Le&ert T. ?ori/ontal eni%n &ositional *erti%o. Neurolo%

1#;##(11):221"#.

43. Le&ert T8 Tiel"il4 P. A &ositional aneu*er 7or

treatent o7 5ori/ontal"4anal eni%n &aro'sal &ositional*erti%o. Larn%os"4o&e. 16;106:#6".

44. 3annu445i 8 Giannoni $8 a%nini . Treatent o7

5ori/ontal sei"4ir4ular 4anal eni%n &aro'sal &ositional*erti%o. J 3esti Res. 1;:1"6.

45. eleiso N8 $aa E8 GuleY 8 Pose T8 Aureli O.

$alan4e in &osterior an+ 5ori/ontal 4anal t&e eni%n &aro'sal&ositional *erti%o e7ore an+ a7ter re&ositionin% aneu*ers. Gait

Z osture 200;2:!20Q!2.46. @i Girolao ,8 Otta*ianni 8 ,4arano E8 i44iotti 8 @i

Nar+o . ostural 4ontrol in 5ori/ontal eni%n &aro'sal&ositional *erti%o. Eur Ar45 Otor5inolarn%ol 2000;2!:2Q!.

47. Gans RE8 ?arrin%ton"Gans A. Treatent e77i4a4 o7

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48. E&le J-. ?uan e'&erien4e 9it5 4analit5 re&ositionin%

aneu"*ers. Ann N A4a+ ,4. 2001;#2:1"11.

49. A&&iani GC8 Catania G8 Ga%liar+i -. A lierator aneu*er

7or t5e treatent o7 5ori/ontal 4anal &aro'sal &ositional*erti%o. Otol Neurotol. 2001;22:66".

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*estiular sste. T5ir+ e+ition. O'7or+ <ni*ersti ress 2001.

51. O5 ?J8 Pi J,8 ?an $I8 Li JG. re+i4tin% a su44ess7ul

treatent in &osterior 4anal eni%n &aro'sal &ositional *erti%o.Neurolo% 200;6:121"22.

52. Nuti @8 Nati C8 assali @. Treatent o7 eni%n &aro'sal

&ositio"nal *erti%o: no nee+ 7or &ost"aneu*er restri4tions. JOtolarn%ol. 2000;122:##0"#.

53. Roerts RA8 Gans RE8 @e$oo+t JL8 Lister JJ. Treatent o7

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54. ,io4eli L8 $ittar R,8 Greters -E. osture restri4tions +o

not inter7ere in t5e results o7 4analit5 re&ositionin% aneu*er.$ra/ J Otor5inolarn%ol. 200!;1(1):!!".

55. -otae+ -8 Osinui O8 Coo JA. E77e4t o7 astoi+

os4illation on t5e out4oe o7 t5e 4analit5 re&ositionin% &ro4e+ure.Larn%os4o&e 200#;11#():126".

56. -a4ias J@8 Ellenso5n A8 -assin%ale ,8 Gerin R. 3iration

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58. ?er+an ,J8 Tusa RJ8 Kee @,8 ro4tor LR8 -atto' @E.

,in%le tre"atent a&&roa45es to eni%n &aro'sal &ositional*erti%o. Ar45 Otolarn%ol ?ea+ Ne4 ,ur%. 1;11(#):#!0"#.

59. uran J8 Cass ,. $eni%n &aro'sal &ositional *erti%o. N

En%l J -e+. 1;#1:1!0"6.

60. Lnn ,8 ool A8 Rose @8 $re R8 ,uan 3. Ran+oi/e+

trial o7 t5e 4analit5 re&ositionin% &ro4e+ure. Otolarn%ol ?ea+Ne4 ,ur%. 1!;11(6):12"20.



144

61. $lale $. Canalit5 re&ositionin% &ro4e+ure. Otolarn%ol

?ea+ Ne4 ,ur%. 16;11#():!0"!.

62. Ku44a G8 3alli ,8 3alli 8 erin 8 -ira E. 5 +o eni%n

&aro'sal &ositional *erti%o e&iso+es re4o*er s&ontaneouslX J3esti Res. 1.:2!".

63. Iai T8 Ito -8 Tae+a N8 <no A8 -atsuna%a T8 ,eine P8 et

al. Natural 4ourse o7 t5e reission o7 *erti%o in &atients 9it5eni%n &aro'sal &ositional *erti%o. Neurolo% 200!;6#:20"1.

64. ,eine P8 Iai T8 ,ato G8 Ito -8 Tae+a N. Natural 5istor o7

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Le&ert aneu*ers. Otolarn%ol ?ea+ Ne4 ,ur%. 2006;1!:!2".

65. Cre*itis L. Treatent o7 anterior 4anal eni%n &aro'sal

&ositional *erti%o a &rolon%e+ 7or4e+ &osition &ro4e+ure. JNeurol Neuro"sur% s45iatr. 200#;!:"1.

66. $uttner <8 ?el45en C?8 $ran+t T?. @ia%nosti4 4riteria 7or

4entral *ersus &eri&5eral &ositionin% nsta%us an+ *erti%o: are*ie9. A4ta Otolarn%ol (,to45). 1;11:1"!.





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