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. 2021 Mar 10:12:618269.
doi: 10.3389/fneur.2021.618269. eCollection 2021.

Clinical and VNG Features in Anterior Canal BPPV-An Analysis of 13 Cases

Prateek Porwal  1 , Ananthu V R  1 , Vishal Pawar  2 , Srinivas Dorasala  3 , Avinash Bijlani  4 , Prem Nair  5 , Ravi Nayar  6
Affiliations

Clinical and VNG Features in Anterior Canal BPPV-An Analysis of 13 Cases

Prateek Porwal et al. Front Neurol. .

Abstract

Objective: To define diagnostic VNG features in anterior canal BPPV during positional testing (Dix-Hallpike, supine head hanging, and McClure Pagnini tests). Study Design: A retrospective study of patients diagnosed with anterior canal BPPV across four referral centers in New Delhi, Kochi, Bangalore, and Dubai. Subjects and Methods: Clinical records of 13 patients with AC BPPV out of 1,350 cases, during a 3-years period, were reviewed and analyzed by four specialists. Results: Four patients had positional down beating nystagmus with symptoms of vertigo during the bilateral DHP maneuver. Seven cases had positional down beating nystagmus only on one side of DHP. Typical down beating nystagmus was seen in 10 out of 13 cases during the straight head hanging maneuver. Down beating torsional nystagmus was seen in 6 out of 13 cases. Down beating with horizontal nystagmus was seen in three cases (in DHP and MCP mainly) while pure down beating nystagmus during SHH was only seen in four cases. Conclusion: We conclude that anterior canal BPPV is a rare but definite entity. It may not be apparent on positional testing the first time, so repeated testing may be needed. The most consistent diagnostic maneuver is SHH though there were patients in which findings could only be elicited using DHP testing. We recommend a testing protocol that includes DHP testing on both sides and SHH. MCP testing may also evoke DBN with or without the torsional component. Reversal of nystagmus on reversal of testing position is unusual but can occur. The Yacovino maneuver is effective in resolving AC BPPV. We also propose a hypothesis that explains why DHP testing is sensitive to AC BPPV on either side, whereas MCP lateral position on one side is only sensitive to AC BPPV on one side. We have explained a possible role for the McClure Pagnini test in side determination and therapeutic implications.

Keywords: Anterior canal BPPV; Benign paroxysmal positional vertigo; Dix Hallpike test; Down beating Nystagmus; McClure Pagnini; VNG; VNG features; Yacovino maneuver.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Figure 1
Figure 1
Case 13—Dix-Hallpike left showing down beating nystagmus from 5 to 40 s (Only vertical movements are shown in this graph).
Figure 2
Figure 2
Case 13—Dix-Hallpike right showing down beating nystagmus from 19 to 48 s (Only vertical movements are shown in this graph).
Figure 3
Figure 3
Case 13—Supine head hanging showing down beating nystagmus from 5 to 25 s. Note that DBN is most prominent in the left eye (Only vertical movements are shown in this graph).
Figure 4
Figure 4
Movement of otoconia in MCP test. The direction of nystagmus during MCP may indicate the side of involvement. But during the DHP test on the right side or an MCP test in the right lateral position, the otoconial debris from the left anterior canal can be expected to move toward the common crus. However, no such movement of otoconial debris is expected in the right anterior canal as it is already in the most dependent position.
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