Diagnostic Role of Head Bending and Lying Down

Diagnostic Role ofHead-Bending and Lying-DownTestsin Lateral Canal Benign Paroxysmal Positional Vertigo

Sertac Yetiser and Dilay Ince

Department of Otorhinolaryngology, Anadolu Medical Center, Kocaeli, Turkey

Objectives: To compare the diagnostic value of the head-bendingtest (HBT), lying-down positioning test (LDPT) and patients re-port to identify the affected canal in video-nystagmographically(VNG) confirmed patients with lateral canal benign paroxysmalpositional vertigo (LC-BPPV).Study Design: Case series with chart review.Setting: Head-bending, lying-down positioning and the head-rollmaneuver (HRM) under VNG guidance. The data were collectedin a referral community hospital.Patients: Seventy-eight patients (32 apogeotropic and 46 geotropicnystagmus) with LC-BPPVwho had been recruited between 2009and 2013 were enrolled in the study.Main Outcome Measures: Patients were tested with the HRMand then were asked about subjectively worse side. Later, they weresubjected to HBT when sitting and the LDPT. The results werecompared and studied with the 1-way ANOVA and chi-squaretests. Statistical significance was set at p G 0.05.Results: Affected side was identified by HRM in 75% of pa-tients with apogeotropic nystagmus and 95.6% of patients with

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

Otol Neurotol 00:00Y00, 2015.

Patients with benign paroxysmal positional vertigo ofthe lateral canal (LC-BPPV) are diagnosed as having geo-tropic or apogeotropic bidirectional nystagmus during thehead-roll maneuver (HRM) in the supine position (1Y3).The type of nystagmus and the severity of vertigo sensa-tion during this test will help diagnose the involved sidewhen the head is turned (1). An analysis of slow phasevelocity of the recorded nystagmus will also guide to de-termine the site with more intense nystagmus. A severe andbrief sense of evoked vertigo is generally worse on the

affected side for geotropic type nystagmus and worse onthe healthy side for apogeotropic type nystagmus. Identi-fication of the affected side is very important in selection ofthe proper direction to apply the barbeque or liberatorymaneuvers (4Y7). However, this task is not always easy toaccomplish because the evoked nystagmus may be equallysevere 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 reportedthat almost 10% of patients with unilateral LC-BPPV mayhave symmetrical nystagmus which makes it difficult todetermine the side of the lesion (8). The examiner then needsto use additional methods for selection of the affected side,such as the head-bending test (HBT) when sitting, the lying-down positioning test (LDPT), or the patients subjectivefeeling of vertigo (9). Patients with LC-BPPV frequentlyexperience a sudden sense of spinningwhen they bend theirhead forward or backward intentionally or unintentionallysuch as when falling asleep while reading a newspaperwhen sitting, lying down from a sitting position, or gettingout 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, AnadoluMedical Center, Cumhuriyet mah, 2255 sok, No:3, Gebze 41400, Kocaeli,Turkey; E-mail: [email protected], [email protected] 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 com-panies toward the completion of the work. Authors have no conflict ofinterest and no disclosures.

Otology & Neurotology00:00Y00 2015, Otology & Neurotology, Inc.

1

Copyright 2015 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.

associated with these conditions. From this observation,Nuti and Asprella proposed a test to confirm the diagnosisof the affected canal in LC-BPPV (10,11). They proposed ahorizontal nystagmus beating to the healthy side in case ofgeotropic nystagmus (posterior arm canalolithiasis; otolithslocated away from cupula) and to the affected side in caseof apogeotropic nystagmus (anterior arm canalolithiasis;otoliths located close to the cupula or cupulolithiasis; oto-liths attached to the cupula) when patients are lying downwith 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 lat-eral canal inwhich therewill be nogravitational force and nomovement of otoliths inside the canal (10,11). Bending thehead 60 degrees forward brings the lateral canal to 30 de-grees with reference to the horizontal plane, and this headmotion causes ampullopetal floating of the otoliths resultingin a nystagmus toward the affected ear in geotropic nys-tagmus, or cupular deflection in the opposite direction, to-ward the unaffected ear in apogeotropic nystagmus (10,11).Changing the head position to 30 degrees backward willalso change the angle of the lateral canal to an approxi-mately vertical position, and the otoliths will move chang-ing their direction and velocity (10,11). On the other hand,bringing the patient quickly from the seated position to thesupine position will push the otoliths downward because ofboth gravity and deceleration forcing them toward theutricle if they are free in the canal or toward the ampulla ifthey are attached to the cupula. Therefore, this move willevoke a nystagmus beating toward the healthy side in the

case of geotropic nystagmus or toward the affected side inthe case of apogeotropic nystagmus.The aim of this study is to compare the diagnostic value

of HBT when sitting, LDPT, and the patients report ofseverity of sense of vertigo during HRM in the supine po-sition in patients with LC-BPPV.

MATERIALS AND METHODS

Seventy-eight patients with LC-BPPV who had been recruitedbetween 2009 and 2013 were enrolled in the study. A verbal and asigned informed consent were obtained from each patient. Theprocedures were in accordance with the ethical standards of thedeclaration of Helsinki and of the institutional review board. Therewere 36 men and 42 women with age ranging from 14 to 84 years(42.28 T 11.29). Duration of symptoms was ranging between2 days and 12 weeks. Main inclusion criteria were normal oto-scopic examination, normal hearing threshold, and no problemsother than BPPV. Those with hearing loss, tinnitus, abnormal eardrum, or other vestibular or neurologic problems and those whoused medication recently which could affect the vestibular systemwere excluded. Data were collected in a referral community hos-pital. All patients were first tested with VNG (Micromedical Tech-nologies, Inc,USA) for spontaneous nystagmus in the seated primarygaze position before starting the test battery and those with spon-taneous nystagmus were excluded from the study. Tests were per-formed in the order of spontaneous nystagmus, HRM, HBT, andLDPT. The type, duration, and direction of nystagmus were re-corded with an infrared wireless video camera. VNG is done bygoggles with closed camera system (open eyes, closed vision) andno 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 seenin patients with LC-BPPV (APO, apogeotropic; GEO, geotropic). Dark arrow indicates the direction of the nystagmus.

2 S. YETISER AND D. INCE

Otology & Neurotology, Vol. 00, No. 00, 2015


Presence of brief latency, short duration, and adaptation oftransient nystagmus were always noted to confirm peripheraltype positional nystagmus. Geotropic or apogeotropic nystag-mus (bi-directional, horizontal) during HRM while the patientwas lying down was initially documented (Fig. 1). The patientshead was first turned to the right side for 3 minutes and then tothe center position. Later, the head was turned to the left side tosee evoked nystagmus. The affected side was determined accordingto the severity of nystagmus as seen on the VNG recording.Nystagmus of greater velocity was on the affected side in patientswith geotropic nystagmus and on the healthy side in patients withapogeotropic nystagmus. Patients were defined as undeterminedlaterality for geotropic or apogeotropic form if the analysis of therecorded images shows similar slow phase eye velocity on bothsides. Patients were also asked about how they felt and which sidewas worse for the sense of vertigo during HRM.Later, the patients were subjected toHBT at sitting in 3 different

positions (Fig. 2). First, the head was quickly bent forward by60 degrees (Position A) while the patient was in the sitting po-sition. Then, the patients head was put in the straight position(position B). This was actually a movement action from positionA to position B (different from primary gaze position to seek forspontaneous nystagmus). Finally, the head was bent backward by30 degrees (position C). This was again a movement action fromposition B to position C. The test was performed with VNG, andeach position was held for 5 minutes to obtain sufficient time torecord the evoked nystagmus. The head was grasped and fixed bythe technician at each position. Finally, the patient was askedto lie down from the sitting position (LDPT) and again evokednystagmus was recorded by VNG (Fig. 3). Horizontal positionalnystagmus seen during LDPT was toward the healthy side inpatients with geotropic nystagmus and toward the affected side in

patients with apogeotropic nystagmus. Positional nystagmus duringHBT in patients with geotropic nystagmus was toward the affectedside in position A and toward the healthy side in positions B and C.However, in patients with apogeotropic nystagmus, it was towardthe healthy side in position A and toward the affected side inpositions B and C.Patients having nystagmus with asymmetric intensity on both

sides during HRM in the supine position under VNG (the affectedside was clear for geotropic or apogeotropic type nystagmus) andthose having nystagmus with almost equal intensity were deter-mined. Patients having no nystagmus during LDPT and/or HBTand those having nystagmus during the tests confirming the af-fected side as detected by HRMwere determined. Finally, patientswho were unable to tell the affected side from the severity of senseof vertigo during the HRM (equal intensity or very mild senseof spinning), and those who reported asymmetric severity of senseof vertigo during the HRM were determined. Mean values werecompared for each group. Patients with apogeotropic nystagmuswere treated with Barbeque, Semonts, or Gufoni maneuvers, andpatients with geotropic nystagmus were treated with Barbeque orGufoni maneuvers. All patients were controlled within 5 to 7 daysafter therapeutic maneuvers. The 1-way ANOVA and chi-squaregoodness of fit tests were used for comparative analysis of thegroups. Statistical significance was set at p G 0.05.

RESULTS

Thirty-two patients had apogeotropic, and 46 patientshad geotropic type nystagmus, which were noted in HRM.Identification of the affected side was possible in 24 of the32 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.

3HEAD-BENDING AND LYING-DOWN TESTS



HRM (11 in right ear and 13 in left ear). Eighteen patientswith apogeotropic nystagmus were able to tell the worse sidein 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 nystagmusduring HBT position B. Twenty-one patients had nystag-mus during LDPT (21/32; 65.6%), but it was comparablewith the side of the affected canal detected by HRM in 15patients (15/32; 46.7%), and it was vertical or not compa-rable 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%) byHRM (21 in right ear and 22 in left ear). Twenty-ninepatients were able to tell the worse side in terms of senseof severity during HRM (29/46; 63%). Thirteen patientshad nystagmus during HBT position A (13/46; 28.3%), and15 patients had nystagmus during HBT position C (15/46;32.6%). None of the patients had nystagmus during HBTposition- B. Twenty four patients had nystagmus duringLDPT (24/46; 52%), but it was comparable with the side ofthe 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 7patients with equal nystagmus on both sides during HRMand 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 arecombined as diagnostic tools, if improvement of symp-toms after therapeutic maneuvers are assumed to enhancethe determination of the laterality. Forty-three patients withgeotropic nystagmus and laterality sign on HRM were res-ponded the treatment. Treatment plan was based on theLDPT findings in 2 patients and was effective in one ofthem. Therefore, the number of patients with cure increasedfrom 93.4% (43/46) to 95.6% (44/46), when combinationof 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 inTable 1. Diagnostic value of both the LDPT and patientsreports was better in patients with apogeotropic nystagmusand also in those with geotropic nystagmus, compared withthe value of HBT. No statistically significant differencewas found when comparing the diagnostic value of HBT inthe 3 positions, LDPT and patients reports between pa-tients with geotropic and those with apogeotropic nystag-mus (p 9 0.05). The number of patients who were curedafter treatment and inwhomdiagnostic evaluationwas basedon LDPT alone was statistically significantly better in pa-tients with apogeotropic nystagmus compared with patients

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




having geotropic nystagmus (p = 0.018). However, whenall diagnostic tests were used together, the overall cure ratein patients with geotropic type nystagmus was statisticallysignificantly better than patients with apogeotropic typenystagmus (p = 0.044).

DISCUSSION

Studies related with the diagnostic issues of LC-BPPVare generally based on HRM only and comparative analysiswith other methods is lacking. Few studies have been pub-lished analyzing the diagnostic value of LDPT to determinethe affected canal in patients with LC-BPPV. Han et al. haveanalyzed the presence of lying-down nystagmus (toward

the healthy ear in geotropic and toward the affected ear inapogeotropic type) in 152 patients with LC-BPPV and haveobserved this nystagmus in 38.2% of patients with docu-mented LC-BPPV (36.4% of the geotropic and 41.5% ofthe apogeotropic type) (9). We have found higher incidenceof evoked nystagmus during LDPT in our series (65.6% forapogeotropic nystagmus and 52% for geotropic nystagmus),although the number of patients is smaller. However, itscontribution to the diagnosis was less than HRM.It seems that it is not always possible to evoke the nys-

tagmus with LDPT. This could be related with the densityand the amount of the otoliths or their distance to the cupulainside the membranous labyrinth to evoke nystagmus orwith the examiner who is unable to do the test adequately

FIG. 4. The overall test results of patients with apogeotropic type nystagmus.

FIG. 5. The overall test results of patients with geotropic type nystagmus.




because the lying down movement should be so quick. Wehave also some concern about the order of the tests.We havedone first HBT, then later LDPT. This may cause dispersalof the debris in some patients. Doing several tests alwaysin the same order is one of the limitations of this study.The order of tests would be randomized to reduce the effectof one test to another one. Several tests may also raise aquestion of fatigability and adaptation, although we alwayscared about resting patients for 15 to 20 minutes. Anotherlimitation could be blinding of investigators. Ideally, a personinterpreting a test should be blinded to the results of all theother tests. Testing and interpretation were made by differentpeople in this study. However, interpretation of all tests wasmade by the sameperson. Finally, some limitationsmay existto raise a general conclusion for the utility of a clinical test ina single center study, which needs to be reviewed by a multicenter study.Choung et al. have reviewed the effect of the so-called

bow and lean test (affected ear was in the same directionas bowing nystagmus in geotropic nystagmus and the samedirection as leaning nystagmus in apogeotropic nystagmus)to determine the side of the affected canal in 26 patientswith LC-BPPV. This test, which was actually similar to theHBT, revealed no nystagmus in 3 patients (11.5%) and wasnot comparable with HRM in the supine position in 7 pa-tients (26.9%) (12). Lee et al. have reviewed the lateralizingvalue of head bending nystagmus in 54 patients with LC-BPPV while sitting (13). Fifteen patients had no head-bending nystagmus (27.8%), and it was not comparablewith head turning asymmetric nystagmus in the supineposition in 5 patients. The overall diagnostic value was63% (34/54).Identification of the affected side with HRM is gener-

ally possible in patients with LC-BPPV in the presenceof nystagmus with asymmetric intensity and the relief ofsymptoms after therapeutic maneuver confirms the de-termination of the laterality. It seems that the cure rate ishigh for both geotropic and apogeotropic type LC-BPPVif the laterality is clearly evident by HRM. Forty-threeof 44 patients with geotropic and 23 of 24 patients withapogeotropic nystagmus responded well at least to one ofthe therapeutic maneuvers. However, HRM indicated theinvolved side in 75% of patients with apogeotropic nys-tagmus and 95.6% of patients with geotropic nystagmusin this series. Therefore, it is an important measure toalways include other diagnostic signs in the test battery toincrease the rate of identification of the involved side.

Our findings do not support the diagnostic contributionof HBT in identification of the affected side. It has beenconcluded in this study that the diagnostic role of patientssubjective feeling of vertigo, which has not been paidmuchattention in previous studies, is reliable and the diagnosticreliability of patients report and LDPT is statistically moresignificant than HBT. However, despite all these diagnos-tic tests, there were 3 patients with bi-directional geotropic(1 patient) and apogeotropic nystagmus (2 patients) withsymmetric severity where the affected side remained un-diagnosed. Several attempts at therapeutic maneuvers wererequired on both sides in these patients, and the cure waseventually delayed. Although it has been scarcely reported,this raises a possibility of a bilateral disease.

CONCLUSION

In conclusion, HRM has the greatest diagnostic value ofpositioning tests in LC-BPPV in this study. LDPT providessome contribution in the diagnosis of LC-BPPV but muchless than HRM. LDPT was useful when combined with theHRM, especially if the patients had symmetric nystagmuson turning their head to either side. Patients subjectivefeeling of vertigo was also a useful test. Therefore, patientsreport and LDPT should be included in the test battery ofpatients with LC-BPPV. However, HBT was not as sensi-tive as other measures in uncertain cases in this series.

Acknowledgments: The authors thank all personnel of thedepartment for their valuable help to the patients. The authors alsothank to Mr. Murat Gul, associate professor, Giresun University,Department of Statistics ([email protected]) for his reviewof the data.

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TABLE 1. Comparative analysis of the test results for patients with geotropic and apogeotropic nystagmus

Tests Geotropic nystagmus (46 patients) Apogeotropic nystagmus (32 patients) p

Rate of nystagmus seen with HBT-A 28.3% 25% 0.275Rate of nystagmus seen with HBT-C 32.6% 21.7% 0.088Rate of nystagmus seen with LDPT 52% 65.6% 0.655Patients subjective feeling of more severe side 63% 56% 0.109Patients benefit based on LDPT 2.2% 12.5% a 0.018Overall cure rate 95.6% (44/46) 84.3% (27/32) a 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 atposition- C.

a Significant p values.




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Diagnostic Role of Head Bending and Lying Down