Akihide Ichimura

Clinical features of paroxysmal positional vertigo presenting combined lesions

Benign paroxysmal positional vertigo (BPPV) is one of the common vestibular disorders. Canalolithiasis is thought to be a likely lesion. A canalith repositioning procedure (CRP by Epley) generally yields good resolution of vertigo and nystagmus. The authors confirmed the efficacy of this procedure on typical BPPV of the posterior semicircular canal type. We designed a new procedure for BPPV of the lateral canal type, which also yielded satisfactory results. BPPV sometimes presents a nystagmus pattern, which suggests multiple lesions. We have seen eight cases of BPPV showing nystagmus that combines both the posterior and the lateral canal types. Combined CRP was performed on these cases, which again gave good clinical results. Other BPPV cases were associated with central lesions. We must be aware that BPPV may involve multiple canals and may be associated with central lesions.

Clinical effect of canal plugging on paroxysmal positional vertigo.

A 63-year-old woman had disabling positional vertigo for four months. She showed intense direction-changing apogeotropic nystagmus. Conservative treatment failed to resolve her vertigo. From the findings of the nystagmus, cupulolithiasis of the right lateral canal was suspected. Plugging of this canal successfully eliminated the nystagmus and positional vertigo. Positional vertigo can sometimes be disabling and unresponsive to conservative therapy. Careful analysis of the nystagmus may allow selection of the most appropriate treatment.

Auditory-pupillary responses in patients with vestibular neuritis.

Pupillary dilation in response to sound stimuli is well established and generally represents a startle reflex to sound. We previously reported that auditory-pupillary responses (APRs) persist with bilateral deafness, and that the pathways mediating APRs involve not only the cochlea but also otolith organs, especially the saccule. Here, we evaluated the vestibulo-autonomic responses in vestibular neuritis (VN) by assessing APRs. Twelve young healthy volunteers without a history of hearing and equilibrium problems and 10 VN patients participated. To clarify the relationship between APRs and vestibular function, especially otolith function, we performed caloric and vestibular-evoked myogenic response testing on VN patients. In normal subjects, we examined APRs when delivering sound stimuli to both sides. In VN patients, we examined APRs when delivering stimuli simultaneously to both sides, to the affected side alone, and then to the unaffected side alone. With binaural stimulation, the pupillary index (PI) - the rate of dilation - of VN patients significantly differed from those of normal subjects. Moreover, in VN patients, PIs of the affected sides were significantly larger than those of the unaffected sides. Our study provides evidence that examining APRs may be useful for evaluating vestibulo-autonomic reflexes, especially otolith-autonomic reflexes.

Auditory-pupillary responses in deaf subjects

Pupillary dilation in response to sound stimuli is well established and is generally considered to represent a startle reflex to sound. We believe that the auditory-pupillary response represents not only a simple startle reflex to sound stimuli but also represents a reaction to stimulation of other sense organs, such as otolith organs. Eight young healthy volunteers without a history of hearing and equilibrium problems and 12 subjects with bilateral deafness participated in this study. Computer pupillography was used to analyze the auditory-pupillary responses of both eyes in all subjects. We found that auditory-pupillary responses occurred even in subjects with bilateral deafness and that this response was comparable to those of normal subjects. We propose that the auditory-pupillary response also relates to vestibular function. Thus, assessing the auditory-pupillary response may be useful for evaluating the vestibulo-autonomic response in patients with peripheral disequilibrium.

Spontaneous inversion of nystagmus without a positional change in the horizontal canal variant of benign paroxysmal positional vertigo.

OBJECTIVE We investigated the neuro-otological findings, including nystagmus, and the clinical course of patients with the horizontal canal variant of benign paroxysmal positional vertigo (HC-BPPV), who showed spontaneous inversion of nystagmus without a positional change. Furthermore, we speculated on the possible mechanism of spontaneous inversion of nystagmus without a positional change. PATIENTS AND METHODS The characteristics of spontaneous inversion of positional nystagmus without a positional change were analyzed in 7 patients with HC-BPPV. RESULTS All patients were diagnosed as having HC-BPPV. During the positional test, the spontaneous inversion of nystagmus was observed in the same head position in all patients. Spontaneous inversion was observed on both sides in 5 patients, and only on 1 side in 2 patients. All patients presented with geotropic nystagmus in the first phase, and ageotropic nystagmus in the second phase. CONCLUSIONS The coexistence of cupulolithiasis and canalolithiasis appears to be a possible mechanism of the spontaneous inversion of positional nystagmus.

Persistent Down-Beating Torsional Positional Nystagmus: Posterior Semicircular Canal Light Cupula?

A 16-year-old boy with rotatory positional vertigo and nausea, particularly when lying down, visited our clinic. Initially, we observed vertical/torsional (downward/leftward) nystagmus in the supine position, and it did not diminish. In the sitting position, nystagmus was not provoked. Neurological examinations were normal. We speculated that persistent torsional down-beating nystagmus was caused by the light cupula of the posterior semicircular canal. This case provides novel insights into the light cupula pathophysiology.