Practice Guidelines for the Diagnosis and Management of Benign Paroxysmal Positional Vertigo Otoneurology Committee of Spanish Otorhinolaryngology and Head and Neck Surgery Consensus Document

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Documento de Consenso de la Comisión de Otoneurología Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1750 "Ancho" => 2333 "Tamanyo" => 150297 ] ] "descripcion" => array:1 [ "en" => "Gufoni manoeuvre for ageotropic nystagmus/Appiani, for cupulolithiasis of the anterior arm of the horizontal canal (right side). We start with the patient sitting on the edge of the bed. (I) We lie the patient down on the affected side (right in this case); (II) we turn the head 45° towards the healthy side (nose facing upwards); (III) we sit the patient upright." ] ] ] "textoCompleto" => "IntroductionBenign paroxysmal positional vertigo (BPPV) is an episodic vestibular syndrome secondary to a disorder caused by the displacement of otoconia that dislodge from the utricular otolithic membrane and shift towards the semi-circular canals. This is a very common disorder that triggers characteristic nystagmus depending on the canal where the otoconia have accumulated, and is usually associated with rotatory vertigo of short duration.The Bárány Society's<a class="elsevierStyleCrossRef" href="#bib0600">1</a> International Classification of Vestibular Disorders established the diagnostic criteria for BPPV. These diagnostic criteria seek to define the different clinical variants of the disease according to the characteristics of the nystagmus observed during positional tests. The classification determines 2 diagnostic categories: established positional syndromes (very common and described in many studies) and controversial and emerging syndromes (much less common and with fewer published studies).Although these diagnostic criteria were created in line with the therapeutic directives of the American Academy of Neurology<a class="elsevierStyleCrossRef" href="#bib0605">2</a> and the American Academy of Otolaryngology-Head and Neck surgery,<a class="elsevierStyleCrossRef" href="#bib0610">3</a> the Bárány Society have not compiled a consensus document on the treatment of BPPV. Moreover, although there are some published reviews in Spanish to disseminate the treatment of BPPV,<a class="elsevierStyleCrossRef" href="#bib0615">4</a> many manoeuvres have been described for the horizontal and anterior canal variants but whose clinical effectiveness has not yet been demonstrated.In this regard, the otoneurology committee of the Spanish Society of Otolaryngology and Head and Neck Surgery (SEORL-CCC) formed a working group to draw up a consensus document for the diagnosis and treatment of BPPV. This document was prepared in line with the diagnostic criteria of the Bárány Society, respecting the international diagnostic codes.The aim of this document is to serve as a practical guide as to how to approach the diagnosis and treatment of BPPV and achieve uniform terminology. Since it is to be evidence-based and straightforward, we decided to limit our exposure to the diagnostic tests and therapeutic manoeuvres for which there are studies with the best levels of evidence or with wider patient series, to a maximum of 2 for each type of BPPV, notwithstanding the use of other variants described in the literature.DefinitionBPPV is an otoconial disorder that causes an episodic vestibular syndrome of short duration, generally under a minute. The syndrome is characterized by nystagmus triggered by the abnormal stimulation caused by otoconia in the semi-circular canal affected. It usually occurs when the patient goes to bed, turns in their bed or bends their head down. Clinically it causes the perception of rotating objects in most cases, although some elderly patients only describe instability with these position changes.<a class="elsevierStyleCrossRef" href="#bib0620">5</a> These symptoms, like nystagmus, are brief (under a minute) and self-limiting, and can result in nausea or vomiting.<a class="elsevierStyleCrossRefs" href="#bib0610">3,6–9</a>The syndrome is paroxysmal and is not accompanied by the hearing disorders (tinnitus and hearing loss) or headache, including migraine, associated with episodic vestibular symptoms.<a class="elsevierStyleCrossRef" href="#bib0600">1</a>The symptoms are basically the same for all 3 canals, there are generally no differences in relation to the spatial orientation of the affected canal. Therefore, the definitive diagnosis lies in the nystagmus observed during specific provocation manouevres.<a class="elsevierStyleCrossRefs" href="#bib0610">3,7,9,10</a>PathophysiologyMost patients with BPPV have a group of free otoconia (canaliths) in the canals. This is termed canalithiasis. When the provocation test is performed, the otoconia displace according to the gravity vector, triggering displacement of endolymph that tilts the canal's cupula, causing the corresponding nystagmus after a latency that varies between 1 and 4s. This nystagmus usually follows a paroxysmal course (crescendo-decrescendo) and is self-limiting, for a maximum of 1min, since once the canalith has stopped moving (when it reaches the most sloping part of the canal in the position adopted), the endolymphatic flow also stops, and the cupula returns to its resting position. When the patient returns to the starting position, the particles displace in the reverse direction, again creating an endolymphatic flow, in this case in the opposite direction to the previous position, with the cupula tilting in the opposite direction and a reverse nystagmus to that which occurred in the first position. This reverse nystagmus can be very useful for confirming a BPPV, although it is not always observed.<a class="elsevierStyleCrossRefs" href="#bib0630">7,9</a>More rarely, the pathophysiological substrate is a cupulolithiasis: the particles adhere to the canal's cupula, in such a way that it becomes sensitive to gravity. When the provocation test is performed the cupula tilts according to the position of its axis with respect to the gravity vector (increasingly the more perpendicular its axis to the gravity vector), but it tilts immediately after the position change, without an endolymphatic flow, and therefore there is practically no latency. Furthermore, the tilting persists while the position is maintained and with it the nystagmus that has been triggered. In cupulolithiasis the nystagmus depends on the position adopted. Depending on the canal and the test performed in the initial starting position, nystagmus might occur if the axis of the cupula forms an angle with gravity. This nystagmus will always have the same direction, irrespective of whether we return to it from the provocation position.<a class="elsevierStyleCrossRefs" href="#bib0630">7,9</a>Therefore:Nystagmus in canalithiasis:Latency: 1–4s; should not exceed 10s.Course: paroxysmal, crescendo/decrescendo.Duration: brief; one minute maximum.Reversal on returning to the starting position: frequent.Nystagmus in cupulolithiasis:Latency: negligible.Course: persistent.Duration: while the position is maintained.In the starting position: if there is nystagmus, it is present whenever this position is adopted, and it is always the same.TerminologyTo describe the syndrome correctly the affected ear and the affected semi-circular canal must be indicated. To match the terminology with that of the Bárány Society, the semi-circular canals must be termed anterior (AC), horizontal (HC) and posterior (PC), indicating the affected ear. For example, a patient with BPPV of the right ear and posterior canal could be abbreviated thus: RPC-BPPV.To describe the mechanism, we will use the terms canalithiasis when the otoconia are free in the semi-circular canal, and cupulolithiasis when they adhere to the cupula and are in contact with the semi-circular crest. We do not recommend the use of terms (in Spanish) such as “canalolitiasis” or “canalitiasis”.Diagnosis is made using positional (diagnostic or provocation) tests, such as the Dix-Hallpike test, avoiding using the terms manoeuvre or test, which can be more confusing.The treatment or therapeutic manoeuvre depends on the affected canal, the canal that is treated must be indicated and we recommend mentioning the author who described it initially. For example, Epley's manoeuvre for RPC.Traditionally, therapeutic manoeuvres were classified as repositioning and liberatory manouvres.<a class="elsevierStyleCrossRefs" href="#bib0650">11,12</a> The former would be based on exposing the canal to gravity to cause displacement of the particles towards the utricle. The liberatory manoeuvres had the same purpose, but would also use inertia, with faster or sudden movements, to cause displacement of the particles in the desired direction (towards the utricle).<a class="elsevierStyleCrossRef" href="#bib0660">13</a> Since, in general, both mechanisms are shared, we will not make this distinction when we mention the therapeutic manoeuvres.Description of NystagmusNystagmus, we always refer to the rapid phase, should be described using the movement of the patient's eyeball in the orbit as the benchmark. The characteristics can be much better observed using a video system, which records the nystagmus, or with Frenzel's goggles that prevent inhibition by gaze fixation. A description of nystagmus must include the direction and sense of movement, the latency and duration.Thus, according to the direction and the sense, the components of nystagmus can be horizontal (right/left), vertical (upbeating/downbeating) and rotatory (clockwise/counter clockwise); for example, nystagmus associated with the posterior canal has a torsional component (clockwise or counter clockwise) associated with an upbeating vertical component.Terms that refer to the position of the head or eye relative to the rest of the body should be avoided, such as geotropic/ageotropic, as well as the patient's own external references. Nystagmus corresponding to a PC-BPPV is often defined as geotropic, but a PC is not defined as such, since a horizontal nystagmus beating towards the Dix-Hallpike test side will also be geotropic. Nystagmus, with its direction and sense components, is essential in reaching a correct diagnosis of BPPV.Canalithiasis of the Posterior Semi-circular CanalSince this is the most common variety,<a class="elsevierStyleCrossRef" href="#bib0665">14</a> and because cupulolithiasis of the PC is still considered a controversial diagnosis,<a class="elsevierStyleCrossRefs" href="#bib0600">1,15</a> it is usually generically termed PC-BPPV, implying canalithiasis.DiagnosisSymptoms comprise vertigo, usually rotatory (in people of advanced age the symptom can be instability<a class="elsevierStyleCrossRef" href="#bib0620">5</a>), of sudden onset and short duration, with vertical plane head movements (going to bed or getting up, looking upwards extending the neck, etc.). Diagnosis is based on provocation tests and the characteristic nystagmus observed.The Dix-Hallpike<a class="elsevierStyleCrossRef" href="#bib0675">16</a> test (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) is the gold standard: the patient sits on the bed, they turn their head 45° towards the side that is to be tested and then they are put into the supine position, extending their head preferably about 15–20° below horizontal; this produces movement on the plane of the corresponding posterior canal which enables ampullofugal displacement of the canalith. For a right-sided Dix-Hallpike (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) the right PC is mobilized, and nystagmus is triggered with an upbeating vertical and counter clockwise torsional component (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The nystagmus is disconjugate (since it corresponds to the stimulation of the vertical canals), the ipsilateral eye shows the torsional component more markedly and the contralateral eye the vertical component. Reference is usually made to how as the gaze moves to the tested side the torsional component increases and when it does so to the contralateral side the vertical component will magnify. However, it is not essential to observe this to make a diagnosis (it is a further characteristic of the eye movements triggered by the vertical canals, not something that is inherent to the paroxysmal positional syndrome).<elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Nystagmus is preceded by a latency period (varying between 1 and 4s and less than 10s), it has a paroxysmal course and its duration is less than a minute.When the patient is seated upright until the starting position, reverse displacement of the canalith (ampullopetal flow) occurs and with it vertical downbeating and clockwise torsional nystagmus, which is less intense (Ewald's third law: Ampullofugal flow produces a stronger response than ampullopetal flow in the vertical canals).The same Dix-Hallpike will be used to test the left PC, but this time turning the head 45° to the left. The nystagmus, triggered in this case by stimulation of the left PC, will be upbeating vertical and clockwise torsional, also disconjugate, more torsional in the left eye and more vertical in the right (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). When we sit the patient upright it will be possible to observe a reverse, less intense, downbeating, counter clockwise torsional nystagmus.It can be difficult to perform a Dix-Hallpike with some patients, generally due to limitations in extending the head. An alternative with the same diagnostic value, that also makes a movement in the plane of the posterior canal, is called the side lying test or Semont test<a class="elsevierStyleCrossRef" href="#bib0680">17</a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The patent is seated at the edge of the bed, to examine the right PC their head will be turned 45° to the left to then lie them down on their right side; once the nystagmus has stopped, the patient is sat upright. To examine the left side, the patient's head is turned to the right and they are placed lying on their left side. The nystagmuses that occur, and their characteristics will be the same as in the Dix-Hallpike tests.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>The characteristics of the nystagmuses observed in each diagnostic test are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.TreatmentTreatment of PSC-BPPV is based on particle relocation manoeuvres. As a rule, pharmacological treatment is not useful in resolving BPPV.The 2 most widely used manoeuvres, and with the most consensus in the literature, with enough class A studies, are the Epley and Semont manoeuvres.The Epley manoeuvre was described in 1992,<a class="elsevierStyleCrossRef" href="#bib0650">11</a> and its generalized use was a turning point in the treatment of BPPV. It seeks to redirect the otoconia from the posterior semi-circular canal to the vestibule through a series of positions that favour their displacement assisted by gravity. The steps to perform the manoeuvre are detailed in <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>The Semont manoeuvre<a class="elsevierStyleCrossRef" href="#bib0655">12</a> seeks to achieve sudden displacement of the otoconia from the posterior semi-circular canal to the utricle. The mechanism for performing the test is shown in <a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>.<elsevierMultimedia ident="fig0020"></elsevierMultimedia>In both tests the onset of an “orthotropic” nystagmus is a sign of good prognosis.<a class="elsevierStyleCrossRefs" href="#bib0685">18,19</a> This is a nystagmus in the second step of the manoeuvres (<a class="elsevierStyleCrossRefs" href="#fig0015">Figs. 3d and 4d</a>), of the same characteristics in terms of direction and sense as that triggered in their initial position. The presence of this nystagmus will show correct displacement of the otoconia the length of the canal in the direction of the utricle and will increase the likelihood that the manoeuvre will be successful; however, its absence does not absolutely discount the efficacy of the manoeuvre. In contrast, in the Epley manoeuvre, the presence of a reverse nystagmus (non-orthotropic) in this second position is an indicator of the probable failure of the manoeuvre.<a class="elsevierStyleCrossRef" href="#bib0695">20</a> Therefore it is advisable to monitor eye movements during the repositioning manoeuvres.Both the Semont and the Epley manoeuvres have proved highly effective in resolving PSC-BPPV,<a class="elsevierStyleCrossRef" href="#bib0700">21</a> with a similar recurrence rate.<a class="elsevierStyleCrossRefs" href="#bib0705">22,23</a> Some authors advocate the use of one over the other, and protocols have even been proposed for their combined and sequential use.<a class="elsevierStyleCrossRef" href="#bib0715">24</a> However, none of these strategies has proven clearly superior. Therefore, the choice of manoeuvre fundamentally depends on the experience of the clinician and possibly on any anatomical difficulties the patient might have for a particular manoeuvre to be performed (severe obesity, spinal rigidity, etc.).The classical recommendations after a manoeuvre, such as avoiding lying towards the treated side, sleeping in a semi-seated position and wearing a cervical collar have not been shown to increase the efficacy of the manoeuvres enough to recommend them.<a class="elsevierStyleCrossRef" href="#bib0720">25</a>BPPV is considered resolved when nystagmus is not observed in the relevant provocation test.<a class="elsevierStyleCrossRef" href="#bib0625">6</a> The problem of when this check should be made has not yet been solved. If it is performed immediately it can result in false negatives, because the particles will have dispersed after the therapeutic manoeuvre.<a class="elsevierStyleCrossRef" href="#bib0625">6</a> And moreover, if the test is performed immediately it is more likely that re-entry or reflux of the particles to another canal will occur.<a class="elsevierStyleCrossRef" href="#bib0725">26</a> On the other hand, if left for long periods, we might interpret a spontaneous resolution as the efficacy of the therapeutic manoeuvre<a class="elsevierStyleCrossRefs" href="#bib0700">21,27,28</a> or a recurrence as “non-resolution”.<a class="elsevierStyleCrossRefs" href="#bib0700">21,22,29,30</a>There are many protocols on how to approach the treatment of BPPV; from performing a single manoeuvre per session and separate sessions over several days to 1 week or repeating the manoeuvres in a single session until the BPPV resolves.<a class="elsevierStyleCrossRefs" href="#bib0685">18,23,26,31–39</a> The use of one manoeuvre per session and reviewing the results after 1 week is most frequently described in the literature.Horizontal Canal Benign Paroxysmal Positional VertigoThere are 2 acknowledged variants of HC-BPPV, canalithiasis and cupulolithiasis, although the former is more common.<a class="elsevierStyleCrossRefs" href="#bib0600">1,3</a> In turn, there are considered to be two subvariants of canalithiasis, depending on whether the particles are in the posterior or anterior arm of the canal.<a class="elsevierStyleCrossRefs" href="#bib0600">1,40–42</a> Therefore, we will refer to 3 different types of HC-BPPV.<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.Canalithiasis of the posterior arm (routinely referred to as the geotropic variant in the literature).</li><li class="elsevierStyleListItem" id="lsti0010">2.Canalithiasis of the anterior arm (usually included in the literature within the so-called ageotropic variant, although not always specified as canalithiasis).</li><li class="elsevierStyleListItem" id="lsti0015">3.Cupulolithiasis (ageotropic variant in the literature).</li></ul>Each of the variants have a different pathophysiological behaviour that will condition diagnosis and treatment.DiagnosisOne of the problems with the horizontal canal is that the diagnostic tests act on both 2 horizontal semi-circular canals at the same time, making it difficult to determine the affected side, which is essential for planning treatment.<a class="elsevierStyleCrossRef" href="#bib0795">40</a>The Pagnini-McClure or roll test is the diagnostic provocation test for the HC.<a class="elsevierStyleCrossRefs" href="#bib0600">1,3</a> It is performed with the patient in a supine position and, ideally with their head bent 30° so that the plane of the 2 horizontal canals is vertical.From the starting supine position the head is turned about 90° to each side, it is strongly recommended to go through the supine position between each lateralization.<a class="elsevierStyleCrossRefs" href="#bib0680">17,42</a>Horizontal nystagmus is triggered in canalithiasis, with a brief latency (no more than 10s), of a crescendo-decrescendo course, and duration of less than a minute, which is<a class="elsevierStyleCrossRefs" href="#bib0600">1,43,44</a>:Posterior arm canalithiasis (geotropic variant) (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>):<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">Right horizontal nystagmus when the head is turned to the right.</li><li class="elsevierStyleListItem" id="lsti0025">Left horizontal nystagmus when the head is turned to the left.</li></ul><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Anterior arm canalithiasis (ageotropic variant) (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>):<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030">Left horizontal nystagmus when the head is turned to the right.</li><li class="elsevierStyleListItem" id="lsti0035">Right horizontal nystagmus when the head is turned to the left.</li></ul><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Since this is canalithiasis, each time the head changes position the particles are displaced according to the gravity vector. Therefore, when going from the lateral decubitus position to the supine position a reverse nystagmus can be observed to that obtained in the previous turn of the head and therefore differs going from a right turn to a left turn. Observation of this nystagmus (which will have a latency and will last for less than a minute) might be very useful in confirming canalithiasis.<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0040">In cupulolithiasis (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>), with the head-roll manoeuvre, a horizontal nystagmus occurs, with no latency, and which persists while in the position, which will be<a class="elsevierStyleCrossRefs" href="#bib0600">1,43,44</a>:<elsevierMultimedia ident="tbl0020"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0045">Left horizontal nystagmus when the head is turned towards the right.</li><li class="elsevierStyleListItem" id="lsti0050">Right horizontal nystagmus when the head is turned towards the left.</li></ul>Given the spatial orientation of the HC ampulla, in the supine decubitus position the cupula is not aligned with the vertical, but slightly in an ampullopetal direction.<a class="elsevierStyleCrossRef" href="#bib0820">45</a> Therefore, it is usual to observe a horizontal nystagmus in the supine decubitus position beating towards the affected side (right if the right ear is affected and left if the left ear is affected). Because the particles adhere to the cupula and are not mobile within the canal, in the supine decubitus position the nystagmus will always beat in the same direction, whatever the position of the previous lateral turn. This nystagmus, with the same pathophysiological basis, can also be seen with the patient in a seated position, and is usually termed spontaneous pseudonystagmus.<a class="elsevierStyleCrossRefs" href="#bib0825">46,47</a>Determination of the affected side in any of the 3 variants of HC-BPPV is based on Ewald's second law: in the HC the ampullopetal deflections generate more intense nystagmus than the ampullofugal deflections.<a class="elsevierStyleCrossRefs" href="#bib0795">40,48</a> Therefore, we believe that is it is more appropriate to refer to the direction of the nystagmus triggered than to the position of the head when it is generated. Thus, for any of the variants, it can be said that the rapid phase of the most intense nystagmus will indicate the affected side. Therefore, we recommend that movements of the head to either side should be of similar amplitude and that each lateral turn should pass through the supine position. It is also important for diagnostic purposes that the movements are not very sudden, as this could add a component of inertia, especially in canalithiasis, which would alter the anticipated direction of the particle displacement, reversing the expected nystagmus and creating confusion in establishing a diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0680">17,49</a>Where there is any doubt, we recommend complementing the provocation test with the flexion and extension manoeuvre (termed the Bow and Lean manoeuvre in the literature).<a class="elsevierStyleCrossRefs" href="#bib0805">42,50–55</a> This test is not based on estimating the intensity of the nystagmus triggered, but rather on its direction, which is due to the spatial layout of the horizontal canals and their alignment with the gravity vector in the flexion and extension movements of the head.Canalithiasis of the posterior arm of the HC (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>):<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0055">Flexion: horizontal nystagmus towards the affected side (there will be ampullopetal displacement of the particles).</li><li class="elsevierStyleListItem" id="lsti0060">Extension: horizontal nystagmus beating towards the healthy side (there will be ampullofugal displacement of the particles).</li><li class="elsevierStyleListItem" id="lsti0065">Therefore, the affected side will be indicated by the direction of the nystagmus on flexion.</li></ul><elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Canalithiasis of the anterior arm (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>):<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0070">Flexion: horizontal nystagmus beating towards the healthy side (ampullofugal displacement of the particles).</li><li class="elsevierStyleListItem" id="lsti0075">Extension: horizontal nystagmus beating towards the affected side (ampullopetal displacement of the particles).</li><li class="elsevierStyleListItem" id="lsti0080">Therefore, the affected side will be indicated by the direction of the nystagmus obtained on extension.</li></ul>Cupulolithiasis (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>):<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0085">Flexion: horizontal nystagmus beating towards the healthy side (the ampulla of the canal will tilt ampullifugally).</li><li class="elsevierStyleListItem" id="lsti0090">Extension: horizontal nystagmus beating towards the affected side (the ampulla of the canal will tilt ampullipetally).</li><li class="elsevierStyleListItem" id="lsti0095">Therefore, the affected side will be indicated by the direction of the nystagmus obtained on extension.</li></ul>It is not unusual to find horizontal positional nystagmus in patients with diverse vestibular disorders (not positional paroxysmal), but they must meet the abovementioned criteria of latency, direction change, duration, etc. to make a specific diagnosis of HC-BPPV.<a class="elsevierStyleCrossRef" href="#bib0875">56</a> In this regard, 2 entities have recently been described that are not BPPV, and that would be associated with alterations in the density of endolymph or of the cupulas.<a class="elsevierStyleCrossRef" href="#bib0880">57</a> These are termed light cupula and heavy cupula syndromes, which would not be caused by the presence of extemporaneous particles. In the case of a light cupula, exploration using the Pagnini-McClure test would show horizontal nystagmus similar to posterior arm canalithiasis, but there would be no latency or paroxysmal composition and the nystagmus would be persistent.<a class="elsevierStyleCrossRefs" href="#bib0805">42,43,53,55,58–61</a> In the case of a heavy cupula, exploration would be similar in all ways to that of an HC cupulolithiasis; the fact that it is not a cupulolithiasis could explain the lack of response to therapeutic manoeuvres.<a class="elsevierStyleCrossRefs" href="#bib0800">41,52,54,57,61</a>TreatmentMany manoeuvres and variants for the treatment of HC-BPPV have been described, but few clinical trials and systematic reviews (Class I and II studies), so that meta-analysis cannot be used either as a tool to help discern the best treatment for those that have been described. And neither is there uniformity in how the manoeuvres are termed or described.Based on class I or II studies, we will only consider the Gufoni and barbecue roll (or Lempert) manoeuvres.Treatment of Posterior Arm Canalithiasis (Geotropic Variant)Gufoni's manoeuvre (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>), also termed Gufoni's manoeuvre for the geotropic variant<a class="elsevierStyleCrossRefs" href="#bib0605">2,3,46,62–67</a>: starting with the subject seated on the edge of the bed, they are then laid down on their healthy side. When the nystagmus disappears (or after 60–90s) the head is turned 45° towards the healthy side (nose towards the bed). When the nystagmus ceases or after 60–90s, the patient is sat upright.<elsevierMultimedia ident="fig0025"></elsevierMultimedia>Lempert or BBQ roll manoeuvre (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>)<a class="elsevierStyleCrossRefs" href="#bib0605">2,46,64,65,68,69</a>: starting with the patient in a supine decubitus position, their head is turned 90° towards the healthy side. In phases set by the duration of the nystagmus (or periods of 60–90s) turns of 90° are made (gradually including the body as the head turns) until the patient is on the affected side (270°) and then they are sat upright.<elsevierMultimedia ident="fig0030"></elsevierMultimedia>Treatment of Anterior Arm CanalithiasisGufoni manoeuvre for the ageotropic variant, also termed Appiani manouevre<a class="elsevierStyleCrossRefs" href="#bib0945">70,71</a> (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>): starting with the patient seated on the edge of the bed, they are then laid on their affected side. After the nystagmus disappears (or after 60–90s) their head is turned 45° towards their healthy side (nose upwards). After the nystagmus disappears the patient is sat upright. The BPPV can resolve with this manoeuvre or the particles might only move to the posterior part of the canal. In this case, the treatment will have to be completed by giving appropriate treatment for this variant.<elsevierMultimedia ident="fig0035"></elsevierMultimedia>Treatment of CupulolithiasisThe same treatment as that for anterior arm canalithiasis will be used (Gufoni manoeuvre for ageotropic variant/Appiani manoeuvre),<a class="elsevierStyleCrossRefs" href="#bib0945">70,71</a> with longer times between the different positions (<a class="elsevierStyleCrossRef" href="#fig0035">Fig. 7</a>). Here we would also expect to convert it initially to a posterior arm canalithiasis, once the particles are released from the cupula, and proceed to complete the treatment with the appropriate manoeuvres.A variant of the barbecue manoeuvre has been described for anterior arm canalithiasis and cupulolithiasis, with an earlier stage in which the head is turned towards the affected side<a class="elsevierStyleCrossRefs" href="#bib0955">72,73</a> (<a class="elsevierStyleCrossRef" href="#fig0040">Fig. 8</a>).<elsevierMultimedia ident="fig0040"></elsevierMultimedia>HC-BPPV is considered resolved when no nystagmus is triggered after the provocation tests.Probable Benign Paroxysmal Positional Vertigo, Spontaneously ResolvedAn absence of nystagmus with the provocation tests in a patient with symptoms suggestive of BPPV does not rule out its diagnosis, since it is possible that there is an insufficient number of particles to generate positional nystagmus. This situation is common in clinical practice and is termed probable BPPV, spontaneously resolved.<a class="elsevierStyleCrossRef" href="#bib0600">1</a>Anterior Canal CanalithiasisThe AC is least frequently affected (3% of BPPV), which is easy to explain given its orientation.<a class="elsevierStyleCrossRefs" href="#bib0965">74,75</a> There are few current series with few cases, therefore there are no class I or II studies on which to base the diagnosis and treatment of AC canalithiasis. It is controversial to an extent, and the Bárány Society classification includes it in the emerging BPPV syndromes.<a class="elsevierStyleCrossRef" href="#bib0600">1</a>DiagnosisAC canalithiasis would be diagnosed by the cephalic hyperextension or Dix-Hallpike test (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>).<a class="elsevierStyleCrossRefs" href="#bib0975">76–78</a> All of these show up nystagmus corresponding to ampullifugal stimulation of the affected AC. As in canalithiasis of all types, the nystagmus is paroxysmal, it has a latency of no more than 10s and a maximum duration of 1min. It is essentially downbeating with a torsional component, often difficult to appreciate (especially by the naked eye), which is clockwise for left AC and counter clockwise for right AC (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>). Although it is difficult to identify, the torsional component would be the indicator of the affected side, as in both the cephalic hyperextension test and the 2 Dix-Hallpike tests, right and left, the 2 anterior canals are stimulated (<a class="elsevierStyleCrossRef" href="#fig0045">Fig. 9</a>).<a class="elsevierStyleCrossRef" href="#bib0645">10</a> When the patient is sat upright, reverse nystagmus can be seen (upbeating and counter clockwise if it is left, and clockwise if right).<elsevierMultimedia ident="fig0045"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia>Persistent downbeating nystagmus is mentioned in the literature (of a duration longer than a minute) and attributed to cupulolithiasis of the anterior canal, but this entity, although possible, cannot yet be considered proven.<a class="elsevierStyleCrossRef" href="#bib0600">1</a>TreatmentMany treatment variants have been speculated, generally developed from treatments of posterior canal BPPV, which would be partially or fully reversed.<a class="elsevierStyleCrossRefs" href="#bib0980">77,79–82</a> The Yacovino manouevre,<a class="elsevierStyleCrossRef" href="#bib1010">83</a> has become particularly popular, which has the advantage of not requiring the affected side to be identified, since it would treat either of the 2 AC (<a class="elsevierStyleCrossRef" href="#fig0050">Fig. 10</a>).<elsevierMultimedia ident="fig0050"></elsevierMultimedia>Posterior Canal CupulolithiasisThere are few described cases and there are no series available to study.Diagnosis would be based on the Dix-Hallpike test. The nystagmus obtained would be in the same direction and sense as for canalithiasis, but with no latency and lasting for the time the position is maintained. If, after the Dix-Hallpike with the patient's head still turned 45° towards the side to be explored, we bend the head 90° (reverse Dix-Hallpike), a reverse nystagmus will be triggered, which is also persistent and without latency, and of less intensity.<a class="elsevierStyleCrossRefs" href="#bib0600">1,6,84</a> In summary:Right PC cupulolithiasis:<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0100">Right Dix-Hallpike: upbeating and counter clockwise nystagmus, persistent without latency.</li><li class="elsevierStyleListItem" id="lsti0105">Right reverse Dix-Hallpike: downbeating and clockwise nystagmus, persistent and without latency.</li></ul>Left PC cupulolithiasis:<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0110">Left Dix-Hallpike: upbeating and clockwise nystagmus, persistent and without latency.</li><li class="elsevierStyleListItem" id="lsti0115">Left reverse Dix-Hallpike: inferior and counter clockwise nystagmus, persistent and without latency.</li></ul>Treatment can be given with the Semont or Epley manoeuvre. The Semont manoeuvre (more sudden) would be expected to give better results for patients with cupulolithiasis, since it would release the otoconia from the cupula.<a class="elsevierStyleCrossRefs" href="#bib0655">12,13</a> However, it has not been possible to demonstrate this.Benign Paroxysmal, Positional Vertigo With Involvement of Multiple CanalsThis is included in the Bárány Society as an emerging diagnosis.<a class="elsevierStyleCrossRef" href="#bib0600">1</a> It is considered that it might be underdiagnosed and would be more common in cases of posttraumatic BPPV. The combination that is most frequently described is of the posterior and horizontal canals of a labyrinth, although any combination would be possible.<a class="elsevierStyleCrossRefs" href="#bib0600">1,85–87</a>The clinical symptoms would be appropriate for the syndrome and on examination there would be more than one positive diagnostic positional test, with the characteristics described for the relevant canal, although nystagmus corresponding to the other affected canal or canals, total or partially overlapping, might affect the diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0600">1,10,86,87</a>We must bear in mind that, whatever the test used, the remaining canals (those not specifically explored) will not stay perpendicular to the force of gravity, so that any particles present in them might displace.<a class="elsevierStyleCrossRefs" href="#bib0645">10,75,88,89</a> Therefore, for example, when a Dix-Hallpike test is performed, the displacement of a particle in the posterior as well as the anterior canal might be triggered (as has been seen when referring specifically to its canalithiasis). Therefore, it is necessary always to describe all the features of nystagmus.Refractory Benign Paroxysmal Positional Vertigo: Persistent and Recurrent Benign Paroxysmal Positional VertigoPersistent Benign Paroxysmal Positional VertigoPartial repositioning manoeuvres are very effective especially for the posterior canal, where it is estimated that 90%–95% of cases are resolved with an average of one to 3 manouevres.<a class="elsevierStyleCrossRefs" href="#bib0625">6,21,23,34,37,90–93</a> This resolution rate is lower for the HC (85%),<a class="elsevierStyleCrossRefs" href="#bib0740">29,34,65,71,90,94</a> and is difficult to calculate, due to the few case studies for SC.However, there are patients (3.5%–12%, depending on the series)<a class="elsevierStyleCrossRefs" href="#bib1070">95–97</a> whose symptoms and nystagmus persist despite repeating the manoeuvres.It is always necessary to confirm a diagnosis, excluding causes of positional vertigo other than BPPV.<a class="elsevierStyleCrossRefs" href="#bib1075">96,97</a> Once a diagnosis of BPPV has been confirmed, various therapeutic possibilities have been described for the PC:<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0120">•Habituation exercises, those proposed by Brandt and Daroff<a class="elsevierStyleCrossRef" href="#bib1085">98</a> being the prototype. Brandt and Daroff's exercises have proven less effective in resolving PC-BPPV than the particle repositioning manouevres,<a class="elsevierStyleCrossRefs" href="#bib0715">24,31</a> but they might play a role for patients for whom these manoeuvres have failed. They have two objectives: the dispersion and disaggregation of otoconia, repeatedly moving them in the canal, and promoting central habituation mechanisms.</li><li class="elsevierStyleListItem" id="lsti0125">•Surgical intervention<a class="elsevierStyleCrossRefs" href="#bib1090">99,100</a>: singular nerve section or occlusion of the posterior semi-circular canal. Reserved for patients who are completely refractory to treatment and those whose symptoms are significantly limiting their quality of life.</li></ul>New proposals are also being developed, such as methylprednisolone injection adjuvant to repositioning manouevres.<a class="elsevierStyleCrossRef" href="#bib1100">101</a>Recurrent Benign Paroxysmal Positional VertigoWhatever the therapeutic manoeuvre used, a recurrence percentage has been reported that increases as the follow-up period increases, even nearing 50%.<a class="elsevierStyleCrossRefs" href="#bib0745">30,90,102,103</a> Two studies performed in our environment<a class="elsevierStyleCrossRefs" href="#bib0705">22,23</a> report a recurrence rate of around 25%, the most frequent being in the first 6–12 months after performing the therapeutic manoeuvre. These recurrences can occur in a different canal and/or in the contralateral ear to that of the first BPPV episode.The treatment does not vary, and the repositioning manoeuvre will be performed for the ear affected by the recurrence.Differential Diagnosis of Benign Paroxysmal Positional VertigoThe disorders that could be confused with BPPV can be grouped into 3 categories: otological, neurological and other entities (<a class="elsevierStyleCrossRefs" href="#tbl0035">Tables 7–9</a>).<a class="elsevierStyleCrossRefs" href="#bib0610">3,17</a><elsevierMultimedia ident="tbl0035"></elsevierMultimedia><elsevierMultimedia ident="tbl0040"></elsevierMultimedia><elsevierMultimedia ident="tbl0045"></elsevierMultimedia>The otological diseases include Meniere's disease, acute unilateral vestibular syndrome (neuritis, labyrinthitis), superior semi-circular canal dehiscence, dilated vestibular aqueduct and perilymphatic fistula.<a class="elsevierStyleCrossRefs" href="#bib0600">1,3,17,104,105</a>Although exploration using positional tests confirms diagnosis, the basic clinical features (trigger of the episodes, their duration and associated hearing loss) can be very helpful in making a differential diagnosis (<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>).The neurological processes that can simulate a BPPV are detailed in <a class="elsevierStyleCrossRef" href="#tbl0040">Table 8</a>.<a class="elsevierStyleCrossRefs" href="#bib0600">1,3,14,17,106–109</a>There is a series of warning signs on examination that can indicate the presence of a paroxysmal positional vertigo of central origin, such as<a class="elsevierStyleCrossRef" href="#bib1140">109</a>:<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0130">•The presence of signs or symptoms of CNS disease (such as gaze-evoked nystagmus).</li><li class="elsevierStyleListItem" id="lsti0135">•Absence of nystagmus reversal when the position is reversed.</li><li class="elsevierStyleListItem" id="lsti0140">•Marked position-induced hyperemesis.</li><li class="elsevierStyleListItem" id="lsti0145">•A direction of nystagmus that does not correspond to the canal explored by the manoeuvre, especially in the following cases:<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0150">∘Persistent vertical positional down-beating nystagmus and with no torsional component.</li><li class="elsevierStyleListItem" id="lsti0155">∘Nystagmus taking different directions in diagnostic manoeuvres performed on repeated occasions (as long as repositioning manoeuvres have not been performed, because in that case the particles might have moved from one canal to another).</li></ul></li><li class="elsevierStyleListItem" id="lsti0160">•Nystagmus of changing direction without changes of head position.</li><li class="elsevierStyleListItem" id="lsti0165">•Onset of nystagmus when the patient is asked to hold their gaze (gaze holding nystagmus).</li><li class="elsevierStyleListItem" id="lsti0170">•Spontaneous nystagmus with no positional manoeuvres (discounting the positional pseudonystagmus of HC-BPPV).</li><li class="elsevierStyleListItem" id="lsti0175">•Nystagmus with no dizziness in positional tests.</li><li class="elsevierStyleListItem" id="lsti0180">•Poor response to therapeutic manoeuvres.</li><li class="elsevierStyleListItem" id="lsti0185">•Multiple recurrences confirmed with diagnostic manoeuvres.</li></ul>We must bear in mind that there is an association between BPPV and other vestibular disorders such as Meniere's disease, vestibular neuritis and migraine. Therefore, if a patient has specific symptoms, we should consider the possibility of their having more than one vestibular disorder simultaneously.<a class="elsevierStyleCrossRefs" href="#bib1145">110–113</a>Imaging Tests for Benign Paroxysmal Positional VertigoImaging tests are not necessary to diagnose BPPV (level of evidence C according to the clinical practice guideline of the American Academy of Otolaryngology).<a class="elsevierStyleCrossRef" href="#bib0610">3</a>Brain MRI is generally indicated if central disease is suspected, as in the following cases<a class="elsevierStyleCrossRef" href="#bib1140">109</a>:<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0190">1)Signs or symptoms of brainstem and/or cerebellar dysfunction.</li><li class="elsevierStyleListItem" id="lsti0195">2)Vertigo and positional nystagmus that are not compatible with stimulation of any canal in particular.</li><li class="elsevierStyleListItem" id="lsti0200">3)Persistent BPPV.</li><li class="elsevierStyleListItem" id="lsti0205">4)Recurrent BPPV on at least 3 occasions confirmed by the appropriate positional tests.</li></ul>Horizontal positional nystagmuses are frequently found in clinical practice that do not fulfil the criteria of HC-BPPV, as well as persistent down-beating vertical nystagmuses with no torsional component, for which MRI would be indicated (within a cerebral infarction screening programme).<a class="elsevierStyleCrossRef" href="#bib1160">113</a> But it is relatively common not to find lesions on imaging tests, particularly in the case of down-beating vertical nystagmus, which makes the diagnostic value of MRI questionable when these nystagmuses are the only change found on exploration.<a class="elsevierStyleCrossRefs" href="#bib1185">118,119</a>This would explain the Bárány Society's inclusion of the term possible BPPV in their classification. Clinically it would be compatible with BPPV, but the nystagmus would not be explained when applying the criteria of each subtype. Once other diseases have been ruled out we might consider it to be a BPPV (multi-canal for example) whose nystagmus we do not know how to interpret.<a class="elsevierStyleCrossRef" href="#bib0600">1</a>Pharmacological Treatment of Benign Paroxysmal Positional VertigoThere is no evidence in the literature for drugs that are effective in the definitive treatment of BPPV or that would substitute the therapeutic manoeuvres (level of evidence C according to the clinical practice guidelines of the American Academy of Otolaryngology).<a class="elsevierStyleCrossRef" href="#bib0610">3</a>Conflicts of InterestThe authors have no conflict of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:20 [ 0 => array:3 [ "identificador" => "xres1108972" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1047854" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1108971" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1047853" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Definition" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Pathophysiology" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Terminology" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Description of Nystagmus" ] ] ] 8 => array:3 [ "identificador" => "sec0030" "titulo" => "Canalithiasis of the Posterior Semi-circular Canal" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Diagnosis" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Treatment" ] ] ] 9 => array:3 [ "identificador" => "sec0045" "titulo" => "Horizontal Canal Benign Paroxysmal Positional Vertigo" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Diagnosis" ] 1 => array:3 [ "identificador" => "sec0055" "titulo" => "Treatment" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0060" "titulo" => "Treatment of Posterior Arm Canalithiasis (Geotropic Variant)" ] 1 => array:2 [ "identificador" => "sec0065" "titulo" => "Treatment of Anterior Arm Canalithiasis" ] 2 => array:2 [ "identificador" => "sec0070" "titulo" => "Treatment of Cupulolithiasis" ] ] ] ] ] 10 => array:2 [ "identificador" => "sec0075" "titulo" => "Probable Benign Paroxysmal Positional Vertigo, Spontaneously Resolved" ] 11 => array:3 [ "identificador" => "sec0080" "titulo" => "Anterior Canal Canalithiasis" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0085" "titulo" => "Diagnosis" ] 1 => array:2 [ "identificador" => "sec0090" "titulo" => "Treatment" ] ] ] 12 => array:2 [ "identificador" => "sec0095" "titulo" => "Posterior Canal Cupulolithiasis" ] 13 => array:2 [ "identificador" => "sec0100" "titulo" => "Benign Paroxysmal, Positional Vertigo With Involvement of Multiple Canals" ] 14 => array:3 [ "identificador" => "sec0105" "titulo" => "Refractory Benign Paroxysmal Positional Vertigo: Persistent and Recurrent Benign Paroxysmal Positional Vertigo" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0110" "titulo" => "Persistent Benign Paroxysmal Positional Vertigo" ] 1 => array:2 [ "identificador" => "sec0115" "titulo" => "Recurrent Benign Paroxysmal Positional Vertigo" ] ] ] 15 => array:2 [ "identificador" => "sec0120" "titulo" => "Differential Diagnosis of Benign Paroxysmal Positional Vertigo" ] 16 => array:2 [ "identificador" => "sec0125" "titulo" => "Imaging Tests for Benign Paroxysmal Positional Vertigo" ] 17 => array:2 [ "identificador" => "sec0130" "titulo" => "Pharmacological Treatment of Benign Paroxysmal Positional Vertigo" ] 18 => array:2 [ "identificador" => "sec0135" "titulo" => "Conflicts of Interest" ] 19 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-04-26" "fechaAceptado" => "2017-05-04" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1047854" "palabras" => array:4 [ 0 => "Benign paroxysmal positional vertigo" 1 => "Diagnosis" 2 => "Treatment" 3 => "Criteria" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1047853" "palabras" => array:4 [ 0 => "Vértigo posicional paroxístico benigno" 1 => "Diagnóstico" 2 => "Tratamiento" 3 => "Criterios" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Benign paroxysmal positional vertigo is the most frequent episodic vestibular disorder. The purpose of this guide, requested by the committee on otoneurology of the Spanish Society of Otolaryngology and Head and Neck Surgery, is to supply a consensus document providing practical guidance for the management of BPPV. It is based on the Barany Society criteria for the diagnosis of BPPV. This guideline provides recommendations on each variant of BPPV, with a description of the different diagnostic tests and the therapeutic manoeuvres. For this purpose, we have selected the tests and manoeuvres supported by evidence-based studies or extensive series. Finally, we have also included a chapter on differential diagnosis and a section relating to general aspects in the management of BPPV." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El vértigo posicional paroxístico benigno (VPPB) es la causa más frecuente de vértigo vestibular episódico. EL propósito de esta guía, encomendada por la Comisión de Otoneurología de la SEORL CCC, es disponer de un documento de consenso que sirva de guía práctica para el manejo del VPPB en la clínica diaria. El punto de partida es la clasificación elaborada por la Barany Society, con sus variantes clínicas. Incluye una descripción de las pruebas diagnósticas y de las maniobras terapéuticas para cada una de las variantes establecidas, habiéndose seleccionado aquellas con estudios con nivel adecuado de evidencia o con suficientes series de soporte. Se ha incluido también un capítulo de diagnóstico diferencial, así como un apartado de aspectos generales básicos en el manejo de los pacientes con VPPB." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Pérez-Vázquez P, Franco-Gutiérrez V, Soto-Varela A, Amor-Dorado JC, Martín-Sanz E, Oliva-Domínguez M, et al. Guía de Práctica Clínica Para el Diagnóstico y Tratamiento del Vértigo Posicional Paroxístico Benigno. Documento de Consenso de la Comisión de Otoneurología Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello. Acta Otorrinolaringol Esp. 2018;69:345–366." ] ] "multimedia" => array:71 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1751 "Ancho" => 2333 "Tamanyo" => 85789 ] ] "descripcion" => array:1 [ "en" => "Dix-Hallpike test for canalithiasis of the posterior canal (right): (a) patient seated on the bed, with their head facing forwards; (b) we turn their head approximately 45° towards one of the 2 sides (in this case to the right); (c) maintaining this head position in relation to the trunk, we lie the patient down, so that their head is approximately 20° below the horizontal; we maintain this position for at least 30s (maximum latency until onset of nystagmus); (d) we sit the patient upright." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1747 "Ancho" => 2333 "Tamanyo" => 97530 ] ] "descripcion" => array:1 [ "en" => "Lateral decubitus test for canalithiasis of the posterior canal (right): (a) the patient is seated in the middle of the bed, with their legs hanging down; (b) we turn their head 45° towards the left side; (c) without changing the position of their head in relation to their trunk, we lie the patient down on their right side; we maintain this position for at least 30s (maximum latency until the onset of nystagmus); (d) we sit the patient upright." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1743 "Ancho" => 2333 "Tamanyo" => 147647 ] ] "descripcion" => array:1 [ "en" => "Epley manoeuvre for canalithiasis of the posterior canal (right side): (a) the patient is seated on the bed, with their head facing forwards; (b) we turn their head approximately 45° to the right; (c) maintaining this head position in relation to the trunk, we lie the patient down, so that their head is approximately 20° below the horizontal; we maintain this position until the nystagmus disappears or for at least 30s; (d) we turn the patient's head 90° to the left, so that it is rotated 45° to the left in relation to the supine decubitus position; we maintain this position until the nystagmus ceases (if it appears) or at least 30s; (e) we turn the patient's head and trunk, en bloc, another 90° to the left, so that the head is rotated 135° to the left in relation to the supine decubitus; we maintain this position until the nystagmus ceases (if it appears) or, at least 30s; (f) we sit the patient upright." ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1750 "Ancho" => 2333 "Tamanyo" => 122441 ] ] "descripcion" => array:1 [ "en" => "Semont manoeuvre for canalithiasis of the posterior canal (right side): (a) the patient is seated in the middle of the bed; (b) we turn their head 45° towards the left side; (c) without modifying the position of the head in relation to the trunk we quickly lie the patient down on their right side; we maintain this position for 4min; (d) without changing the position of the head in relation to the trunk, we quickly turn the patient 180° so that they are lying on their left side with their face towards the bed; we maintain this position for another 4min; (e) we sit the patient upright." ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1747 "Ancho" => 2333 "Tamanyo" => 112092 ] ] "descripcion" => array:1 [ "en" => "Gufoni manoeuvre for canalithiasis of the posterior arm of the horizontal canal (left side). We start with the patient seated on the edge of the bed: (I) we lie the patient down on their health side (in this case the right side); (II) we turn the patient's head 45° towards the health side (with their nose facing the bed); (III) we sit the patient upright." ] ] 5 => array:7 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1747 "Ancho" => 2333 "Tamanyo" => 140808 ] ] "descripcion" => array:1 [ "en" => "Lempert or barbecue manoeuvre for canalithiasis of the posterior arm of the horizontal canal (right side). Starting in the supine decubitus position we gradually turn the patient towards their healthy side: (I) we turn their head towards the healthy side (left in this case); (II) we turn their body to the left; (III) we turn their head another 45° towards the healthy side (they will be looking downwards); (IV) we turn the patient's body to the left, leaving them fully in the prone position; (V) we turn their body 45° towards the left; (VI) we sit the patient upright." ] ] 6 => array:7 [ "identificador" => "fig0035" "etiqueta" => "Figure 7" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr7.jpeg" "Alto" => 1750 "Ancho" => 2333 "Tamanyo" => 150297 ] ] "descripcion" => array:1 [ "en" => "Gufoni manoeuvre for ageotropic nystagmus/Appiani, for cupulolithiasis of the anterior arm of the horizontal canal (right side). We start with the patient sitting on the edge of the bed. (I) We lie the patient down on the affected side (right in this case); (II) we turn the head 45° towards the healthy side (nose facing upwards); (III) we sit the patient upright." ] ] 7 => array:7 [ "identificador" => "fig0040" "etiqueta" => "Figure 8" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr8.jpeg" "Alto" => 1750 "Ancho" => 2333 "Tamanyo" => 139254 ] ] "descripcion" => array:1 [ "en" => "Modification of the barbecue manoeuvre for canalithiasis of the anterior arm of horizontal canal (right side). Starting in the supine decubitus position the patient's head is turned towards the affected side (right in this case), to then start the barbecue manoeuvre from this position, described in <a class="elsevierStyleCrossRef" href="#fig0030">Figure 6</a>." ] ] 8 => array:7 [ "identificador" => "fig0045" "etiqueta" => "Figure 9" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr9.jpeg" "Alto" => 1746 "Ancho" => 2333 "Tamanyo" => 154854 ] ] "descripcion" => array:1 [ "en" => "Diagnostic tests for canalithiasis of the anterior canal." ] ] 9 => array:7 [ "identificador" => "fig0050" "etiqueta" => "Figure 10" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr10.jpeg" "Alto" => 1738 "Ancho" => 2333 "Tamanyo" => 134042 ] ] "descripcion" => array:1 [ "en" => "Yacovino manoeuvre for canalithiasis of the anterior canal (irrespective of the side): starting with the patient seated on the bed (a), they are put into the cephalic hyperextension position (b), after 30s (or after the nystagmus has ceased) the head is rapidly bent until the chin touches the chest (c). After 30s (or the nystagmus has ceased) the patient is sat upright (d)." ] ] 10 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Side \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnostic test \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus after sitting upright \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="middle">Right PC</td><td class="td" title="table-entry " align="left" valign="top">Right Dix-Hallpike test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="201811180609248801"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top"><elsevierMultimedia ident="201811180609248802"></elsevierMultimedia></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Right lateral decubitus test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="201811180609248803"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="middle">Left PC</td><td class="td" title="table-entry " align="left" valign="top">Left Dix-Hallpike test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="201811180609248804"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="2" align="left" valign="top"><elsevierMultimedia ident="201811180609248805"></elsevierMultimedia></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Left lateral decubitus test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="201811180609248806"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1897582.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Diagnosis of Canalithiasis of the Posterior Canal." ] ] 11 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Affected side</th><th class="td" title="table-head " align="center" valign="top" scope="col">Position in the cephalic rotation test \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Affected side</th></tr><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Left</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Right</th></tr><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="middle">Canalithiasis HC, posterior arm</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="201811180609248807"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Latency <10s duration <1min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="201811180609248808"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="201811180609248809"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488010"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="2018111806092488011"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488012"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488013"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1897580.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Diagnosis of Canalithiasis of the Posterior Arm of the Horizontal Canal." ] ] 12 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Affected side</th><th class="td" title="table-head " align="left" valign="top" scope="col">Position in the head roll test \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Affected side</th></tr><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Left</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Right</th></tr><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="middle">Canalithiasis HC, anterior arm</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488014"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="3" align="left" valign="middle">Latency <10s duration <1min</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="2018111806092488015"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488016"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488017"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="2018111806092488018"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488019"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488020"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1897581.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Diagnosis of Canalithiasis of the Anterior Arm of the Horizontal Canal." ] ] 13 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Affected side</th><th class="td" title="table-head " align="center" valign="top" scope="col">Position in the head roll test \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Affected side</th></tr><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Left</th><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Right</th></tr><tr title="table-row"><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="3" align="left" valign="middle">Cupulolithiasis HC</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488021"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488022"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488023"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " rowspan="3" align="left" valign="middle">Latency: no duration: while the position is maintained</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="2018111806092488024"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488025"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488026"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="2018111806092488027"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488028"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488029"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1897577.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Diagnosis of Cupulolithiasis of the Horizontal Canal." ] ] 14 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Affected side \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " rowspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Bow and Lean manoeuvre</th><th class="td" title="table-head " align="left" valign="top" scope="col">Affected side \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Right \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Left \t\t\t\t\t\t\n \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Position \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="middle">Posterior arm canalithiasis</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488030"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488031"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488032"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="2018111806092488033"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488034"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488035"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="middle">Anterior arm canalithiasis</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488036"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488037"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488038"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="2018111806092488039"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488040"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488041"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="2" align="left" valign="middle">Cupulolithiasis</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488042"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488043"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488044"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="2018111806092488045"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488046"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488047"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1897583.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Bow and Lean Manoeuvre to Determine the Side in the Three Types of BPPV of the Horizontal Canal." ] ] 15 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at6" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Affected left side</th><th class="td" title="table-head " align="center" valign="top" scope="col">Diagnostic test \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Affected right side</th></tr><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Duration \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Latency \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Latency \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Duration \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><1min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><10seg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488048"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488049"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488050"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><10seg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><1min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488051"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><elsevierMultimedia ident="2018111806092488052"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1897578.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Nystagmus Obtained in the Diagnostic Tests for Canalithiasis of the Anterior Canal." ] ] 16 => array:8 [ "identificador" => "tbl0035" "etiqueta" => "Table 7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at7" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnosis \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Trigger \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Duration \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Hearing loss associated with the episode of vertigo \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Meniere's disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hours \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Unilateral vestibulopathy (neuritis, labyrinthitis) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Hours \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Possible \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Perilymphatic fistula, anterior canal fistula \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Pressure, sound \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Minutes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Possible \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BPPV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Changes of position \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><1min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1897579.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Differential Diagnosis With Other Otological Processes." ] ] 17 => array:8 [ "identificador" => "tbl0040" "etiqueta" => "Table 8" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at8" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Vestibular migraine</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Vestibular paroxysmia</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lesions in the structures around the 4th ventricle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Demyelinizing lesions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cerebellar lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Tumours \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Brainstem lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Ischaemic lesions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Arnold–Chiari disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Degenerative lesions \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1897576.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Neurological Processes That Might Simulate a BPPV." ] ] 18 => array:8 [ "identificador" => "tbl0045" "etiqueta" => "Table 9" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at9" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Orthostatic hypotension<a class="elsevierStyleCrossRefs" href="#bib1135">108,113–115</a></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Panic or anxiety disorders<a class="elsevierStyleCrossRefs" href="#bib0610">3,108,113,114</a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Drugs<a class="elsevierStyleCrossRef" href="#bib0610">3</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Mysoline, carbamazepine, phenytoin, lithium, sedatives, antihypertensives \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Rotational cervical vertigo<a class="elsevierStyleCrossRef" href="#bib1175">116</a></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Positional convergence spasm<a class="elsevierStyleCrossRef" href="#bib1180">117</a></td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1897575.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Other Entities That Might Emulate a BPPV." ] ] 19 => array:5 [ "identificador" => "201811180609248801" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 189 "Ancho" => 237 "Tamanyo" => 6454 ] ] ] 20 => array:5 [ "identificador" => "201811180609248802" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx5.jpeg" "Alto" => 198 "Ancho" => 176 "Tamanyo" => 6512 ] ] ] 21 => array:5 [ "identificador" => "201811180609248803" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx2.jpeg" "Alto" => 204 "Ancho" => 247 "Tamanyo" => 7207 ] ] ] 22 => array:5 [ "identificador" => "201811180609248804" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx3.jpeg" "Alto" => 176 "Ancho" => 237 "Tamanyo" => 6026 ] ] ] 23 => array:5 [ "identificador" => "201811180609248805" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx6.jpeg" "Alto" => 199 "Ancho" => 175 "Tamanyo" => 6538 ] ] ] 24 => array:5 [ "identificador" => "201811180609248806" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx4.jpeg" "Alto" => 190 "Ancho" => 237 "Tamanyo" => 6589 ] ] ] 25 => array:5 [ "identificador" => "201811180609248807" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx9.jpeg" "Alto" => 522 "Ancho" => 1222 "Tamanyo" => 36170 ] ] ] 26 => array:5 [ "identificador" => "201811180609248808" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx7.jpeg" "Alto" => 415 "Ancho" => 167 "Tamanyo" => 2773 ] ] ] 27 => array:5 [ "identificador" => "201811180609248809" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx10.jpeg" "Alto" => 1017 "Ancho" => 461 "Tamanyo" => 35905 ] ] ] 28 => array:5 [ "identificador" => "2018111806092488010" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx12.jpeg" "Alto" => 244 "Ancho" => 79 "Tamanyo" => 1493 ] ] ] 29 => array:5 [ "identificador" => "2018111806092488011" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx8.jpeg" "Alto" => 245 "Ancho" => 80 "Tamanyo" => 1536 ] ] ] 30 => array:5 [ "identificador" => "2018111806092488012" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx11.jpeg" "Alto" => 1027 "Ancho" => 442 "Tamanyo" => 36263 ] ] ] 31 => array:5 [ "identificador" => "2018111806092488013" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx13.jpeg" "Alto" => 415 "Ancho" => 166 "Tamanyo" => 2665 ] ] ] 32 => array:5 [ "identificador" => "2018111806092488014" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx16.jpeg" "Alto" => 510 "Ancho" => 1203 "Tamanyo" => 36639 ] ] ] 33 => array:5 [ "identificador" => "2018111806092488015" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx14.jpeg" "Alto" => 245 "Ancho" => 79 "Tamanyo" => 1363 ] ] ] 34 => array:5 [ "identificador" => "2018111806092488016" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx17.jpeg" "Alto" => 1002 "Ancho" => 408 "Tamanyo" => 32321 ] ] ] 35 => array:5 [ "identificador" => "2018111806092488017" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx19.jpeg" "Alto" => 415 "Ancho" => 166 "Tamanyo" => 2816 ] ] ] 36 => array:5 [ "identificador" => "2018111806092488018" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx15.jpeg" "Alto" => 415 "Ancho" => 166 "Tamanyo" => 2878 ] ] ] 37 => array:5 [ "identificador" => "2018111806092488019" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx18.jpeg" "Alto" => 1002 "Ancho" => 460 "Tamanyo" => 33294 ] ] ] 38 => array:5 [ "identificador" => "2018111806092488020" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx20.jpeg" "Alto" => 244 "Ancho" => 79 "Tamanyo" => 1252 ] ] ] 39 => array:5 [ "identificador" => "2018111806092488021" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx21.jpeg" "Alto" => 56 "Ancho" => 245 "Tamanyo" => 1253 ] ] ] 40 => array:5 [ "identificador" => "2018111806092488022" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx24.jpeg" "Alto" => 530 "Ancho" => 1023 "Tamanyo" => 31842 ] ] ] 41 => array:5 [ "identificador" => "2018111806092488023" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx27.jpeg" "Alto" => 56 "Ancho" => 245 "Tamanyo" => 1183 ] ] ] 42 => array:5 [ "identificador" => "2018111806092488024" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx22.jpeg" "Alto" => 244 "Ancho" => 79 "Tamanyo" => 1332 ] ] ] 43 => array:5 [ "identificador" => "2018111806092488025" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx25.jpeg" "Alto" => 1158 "Ancho" => 466 "Tamanyo" => 36672 ] ] ] 44 => array:5 [ "identificador" => "2018111806092488026" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx28.jpeg" "Alto" => 415 "Ancho" => 166 "Tamanyo" => 2947 ] ] ] 45 => array:5 [ "identificador" => "2018111806092488027" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx23.jpeg" "Alto" => 414 "Ancho" => 166 "Tamanyo" => 2773 ] ] ] 46 => array:5 [ "identificador" => "2018111806092488028" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx26.jpeg" "Alto" => 1097 "Ancho" => 496 "Tamanyo" => 34754 ] ] ] 47 => array:5 [ "identificador" => "2018111806092488029" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx29.jpeg" "Alto" => 244 "Ancho" => 79 "Tamanyo" => 1258 ] ] ] 48 => array:5 [ "identificador" => "2018111806092488030" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx30.jpeg" "Alto" => 76 "Ancho" => 284 "Tamanyo" => 1421 ] ] ] 49 => array:5 [ "identificador" => "2018111806092488031" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx36.jpeg" "Alto" => 381 "Ancho" => 1636 "Tamanyo" => 45836 ] ] ] 50 => array:5 [ "identificador" => "2018111806092488032" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx42.jpeg" "Alto" => 76 "Ancho" => 284 "Tamanyo" => 1564 ] ] ] 51 => array:5 [ "identificador" => "2018111806092488033" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx31.jpeg" "Alto" => 76 "Ancho" => 284 "Tamanyo" => 1502 ] ] ] 52 => array:5 [ "identificador" => "2018111806092488034" "tipo" => "MULTIMEDIAFIGURA" 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Review article

Practice Guidelines for the Diagnosis and Management of Benign Paroxysmal Positional Vertigo Otoneurology Committee of Spanish Otorhinolaryngology and Head and Neck Surgery Consensus Document

Guía de Práctica Clínica Para el Diagnóstico y Tratamiento del Vértigo Posicional Paroxístico Benigno. Documento de Consenso de la Comisión de Otoneurología Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello

Paz Pérez-Vázqueza,

Corresponding author

paz.perez@sespa.es

Corresponding author.

, Virginia Franco-Gutiérrezb, Andrés Soto-Varelac,d, Juan Carlos Amor-Doradoe, Eduardo Martín-Sanzf, Manuel Oliva-Domínguezg, Jose A. Lopez-Escamezh,i

a Servicio de ORL, Hospital de Cabueñes, Gijón, Spain

b Hospital Universitario Marqués de Valdecilla Santander, Spain

c Unidad de Otoneurología, Servicio de Otorrinolaringología, Complexo Hospitalario Universitario de Santiago Santiago de Compostela, Spain

d Departamento de Cirugía y Especialidades Médico-Quirúrgicas, Universidad de Santiago de Compostela, Santiago de Compostela, Spain

e Servicio de Otorrinolaringología, Hospital Can Misses, Ibiza, Spain

f Unidad de Otoneurología, Servicio de ORL, Hospital Universitario de Getafe, Madrid, Spain

g Servicio de ORL, Hospital Costa del Sol, Marbella, Spain

h Otology & Neurotology Group CTS495, Department of Genomic Medicine-Centre for Genomics and Oncological Research – Pfizer/Universidad de Granada/Junta de Andalucía (GENYO), Granada, Spain

i Departamento de Otolaringología, Instituto de Investigación Biosanitaria ibs, Complejo Hospitalario Universidad de Granada (CHUGRA), Granada, Spain

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These diagnostic criteria seek to define the different clinical variants of the disease according to the characteristics of the nystagmus observed during positional tests&#46; The classification determines 2 diagnostic categories&#58; established positional syndromes &#40;very common and described in many studies&#41; and controversial and emerging syndromes &#40;much less common and with fewer published studies&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Although these diagnostic criteria were created in line with the therapeutic directives of the American Academy of Neurology<a class="elsevierStyleCrossRef" href="#bib0605"><span class="elsevierStyleSup">2</span></a> and the American Academy of Otolaryngology-Head and Neck surgery&#44;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">3</span></a> the B&#225;r&#225;ny Society have not compiled a consensus document on the treatment of BPPV&#46; Moreover&#44; although there are some published reviews in Spanish to disseminate the treatment of BPPV&#44;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">4</span></a> many manoeuvres have been described for the horizontal and anterior canal variants but whose clinical effectiveness has not yet been demonstrated&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In this regard&#44; the otoneurology committee of the Spanish Society of Otolaryngology and Head and Neck Surgery &#40;SEORL-CCC&#41; formed a working group to draw up a consensus document for the diagnosis and treatment of BPPV&#46; This document was prepared in line with the diagnostic criteria of the B&#225;r&#225;ny Society&#44; respecting the international diagnostic codes&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this document is to serve as a practical guide as to how to approach the diagnosis and treatment of BPPV and achieve uniform terminology&#46; Since it is to be evidence-based and straightforward&#44; we decided to limit our exposure to the diagnostic tests and therapeutic manoeuvres for which there are studies with the best levels of evidence or with wider patient series&#44; to a maximum of 2 for each type of BPPV&#44; notwithstanding the use of other variants described in the literature&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Definition</span><p id="par0030" class="elsevierStylePara elsevierViewall">BPPV is an otoconial disorder that causes an episodic vestibular syndrome of short duration&#44; generally under a minute&#46; The syndrome is characterized by nystagmus triggered by the abnormal stimulation caused by otoconia in the semi-circular canal affected&#46; It usually occurs when the patient goes to bed&#44; turns in their bed or bends their head down&#46; Clinically it causes the perception of rotating objects in most cases&#44; although some elderly patients only describe instability with these position changes&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">5</span></a> These symptoms&#44; like nystagmus&#44; are brief &#40;under a minute&#41; and self-limiting&#44; and can result in nausea or vomiting&#46;<a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">3&#44;6&#8211;9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The syndrome is paroxysmal and is not accompanied by the hearing disorders &#40;tinnitus and hearing loss&#41; or headache&#44; including migraine&#44; associated with episodic vestibular symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">1</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The symptoms are basically the same for all 3 canals&#44; there are generally no differences in relation to the spatial orientation of the affected canal&#46; Therefore&#44; the definitive diagnosis lies in the nystagmus observed during specific provocation manouevres&#46;<a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">3&#44;7&#44;9&#44;10</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Pathophysiology</span><p id="par0045" class="elsevierStylePara elsevierViewall">Most patients with BPPV have a group of free otoconia &#40;canaliths&#41; in the canals&#46; This is termed <span class="elsevierStyleItalic">canalithiasis</span>&#46; When the provocation test is performed&#44; the otoconia displace according to the gravity vector&#44; triggering displacement of endolymph that tilts the canal&#39;s cupula&#44; causing the corresponding nystagmus after a latency that varies between 1 and 4<span class="elsevierStyleHsp" style=""></span>s&#46; This nystagmus usually follows a paroxysmal course &#40;<span class="elsevierStyleItalic">crescendo-decrescendo</span>&#41; and is self-limiting&#44; for a maximum of 1<span class="elsevierStyleHsp" style=""></span>min&#44; since once the canalith has stopped moving &#40;when it reaches the most sloping part of the canal in the position adopted&#41;&#44; the endolymphatic flow also stops&#44; and the cupula returns to its resting position&#46; When the patient returns to the starting position&#44; the particles displace in the reverse direction&#44; again creating an endolymphatic flow&#44; in this case in the opposite direction to the previous position&#44; with the cupula tilting in the opposite direction and a reverse nystagmus to that which occurred in the first position&#46; This reverse nystagmus can be very useful for confirming a BPPV&#44; although it is not always observed&#46;<a class="elsevierStyleCrossRefs" href="#bib0630"><span class="elsevierStyleSup">7&#44;9</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">More rarely&#44; the pathophysiological substrate is a <span class="elsevierStyleItalic">cupulolithiasis</span>&#58; the particles adhere to the canal&#39;s cupula&#44; in such a way that it becomes sensitive to gravity&#46; When the provocation test is performed the cupula tilts according to the position of its axis with respect to the gravity vector &#40;increasingly the more perpendicular its axis to the gravity vector&#41;&#44; but it tilts immediately after the position change&#44; without an endolymphatic flow&#44; and therefore there is practically no latency&#46; Furthermore&#44; the tilting persists while the position is maintained and with it the nystagmus that has been triggered&#46; In cupulolithiasis the nystagmus depends on the position adopted&#46; Depending on the canal and the test performed in the initial starting position&#44; nystagmus might occur if the axis of the cupula forms an angle with gravity&#46; This nystagmus will always have the same direction&#44; irrespective of whether we return to it from the provocation position&#46;<a class="elsevierStyleCrossRefs" href="#bib0630"><span class="elsevierStyleSup">7&#44;9</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Therefore&#58;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Nystagmus in canalithiasis&#58;</p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Latency</span>&#58; 1&#8211;4<span class="elsevierStyleHsp" style=""></span>s&#59; should not exceed 10<span class="elsevierStyleHsp" style=""></span>s&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Course&#58; paroxysmal&#44; crescendo&#47;decrescendo&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Duration</span>&#58; brief&#59; one minute maximum&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Reversal on returning to the starting position&#58; frequent&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">Nystagmus in cupulolithiasis&#58;</p><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Latency&#58;</span> negligible&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Course</span>&#58; persistent&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Duration&#58;</span> while the position is maintained&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In the starting position&#58; if there is nystagmus&#44; it is present whenever this position is adopted&#44; and it is always the same&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Terminology</span><p id="par0115" class="elsevierStylePara elsevierViewall">To describe the syndrome correctly the affected ear and the affected semi-circular canal must be indicated&#46; To match the terminology with that of the B&#225;r&#225;ny Society&#44; <span class="elsevierStyleItalic">the semi-circular canals must be termed anterior</span> &#40;<span class="elsevierStyleItalic">AC</span>&#41;&#44; <span class="elsevierStyleItalic">horizontal</span> &#40;<span class="elsevierStyleItalic">HC</span>&#41; <span class="elsevierStyleItalic">and posterior</span> &#40;<span class="elsevierStyleItalic">PC</span>&#41;&#44; indicating the affected ear&#46; For example&#44; a patient with BPPV of the right ear and posterior canal could be abbreviated thus&#58; RPC-BPPV&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">To describe the mechanism&#44; we will use the terms <span class="elsevierStyleItalic">canalithiasis</span> when the otoconia are free in the semi-circular canal&#44; and <span class="elsevierStyleItalic">cupulolithiasis</span> when they adhere to the cupula and are in contact with the semi-circular crest&#46; We do not recommend the use of terms &#40;in Spanish&#41; such as &#8220;<span class="elsevierStyleItalic">canalolitiasis</span>&#8221; or &#8220;<span class="elsevierStyleItalic">canalitiasis</span>&#8221;&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Diagnosis</span> is made using <span class="elsevierStyleItalic">positional</span> &#40;<span class="elsevierStyleItalic">diagnostic or provocation</span>&#41; <span class="elsevierStyleItalic">tests</span>&#44; such as the Dix-Hallpike test&#44; avoiding using the terms manoeuvre or test&#44; which can be more confusing&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">treatment or therapeutic manoeuvre</span> depends on the affected canal&#44; the canal that is treated must be indicated and we recommend mentioning the author who described it initially&#46; For example&#44; Epley&#39;s manoeuvre for RPC&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Traditionally&#44; therapeutic manoeuvres were classified as repositioning and liberatory manouvres&#46;<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">11&#44;12</span></a> The former would be based on exposing the canal to gravity to cause displacement of the particles towards the utricle&#46; The liberatory manoeuvres had the same purpose&#44; but would also use inertia&#44; with faster or sudden movements&#44; to cause displacement of the particles in the desired direction &#40;towards the utricle&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0660"><span class="elsevierStyleSup">13</span></a> Since&#44; in general&#44; both mechanisms are shared&#44; we will not make this distinction when we mention the therapeutic manoeuvres&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Description of Nystagmus</span><p id="par0140" class="elsevierStylePara elsevierViewall">Nystagmus&#44; we always refer to the <span class="elsevierStyleItalic">rapid phase</span>&#44; should be described using the movement of the patient&#39;s eyeball in the orbit as the benchmark&#46; The characteristics can be much better observed using a video system&#44; which records the nystagmus&#44; or with Frenzel&#39;s goggles that prevent inhibition by gaze fixation&#46; A description of nystagmus must include the <span class="elsevierStyleItalic">direction</span> and <span class="elsevierStyleItalic">sense</span> of movement&#44; the <span class="elsevierStyleItalic">latency</span> and <span class="elsevierStyleItalic">duration</span>&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Thus&#44; according to the <span class="elsevierStyleItalic">direction and the sense</span>&#44; the components of nystagmus can be <span class="elsevierStyleItalic">horizontal</span> &#40;right&#47;left&#41;&#44; <span class="elsevierStyleItalic">vertical</span> &#40;upbeating&#47;downbeating&#41; and <span class="elsevierStyleItalic">rotatory</span> &#40;clockwise&#47;counter clockwise&#41;&#59; for example&#44; nystagmus associated with the posterior canal has a torsional component &#40;clockwise or counter clockwise&#41; associated with an upbeating vertical component&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Terms that refer to the position of the head or eye relative to the rest of the body should be avoided&#44; such as geotropic&#47;ageotropic&#44; as well as the patient&#39;s own external references&#46; Nystagmus corresponding to a PC-BPPV is often defined as geotropic&#44; but a PC is not defined as such&#44; since a horizontal nystagmus beating towards the Dix-Hallpike test side will also be geotropic&#46; Nystagmus&#44; with its direction and sense components&#44; is essential in reaching a correct diagnosis of BPPV&#46;</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Canalithiasis of the Posterior Semi-circular Canal</span><p id="par0155" class="elsevierStylePara elsevierViewall">Since this is the most common variety&#44;<a class="elsevierStyleCrossRef" href="#bib0665"><span class="elsevierStyleSup">14</span></a> and because cupulolithiasis of the PC is still considered a controversial diagnosis&#44;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">1&#44;15</span></a> it is usually generically termed PC-BPPV&#44; implying canalithiasis&#46;</p><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Diagnosis</span><p id="par0160" class="elsevierStylePara elsevierViewall">Symptoms comprise vertigo&#44; usually rotatory &#40;in people of advanced age the symptom can be instability<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">5</span></a>&#41;&#44; of sudden onset and short duration&#44; with vertical plane head movements &#40;going to bed or getting up&#44; looking upwards extending the neck&#44; etc&#46;&#41;&#46; Diagnosis is based on provocation tests and the characteristic nystagmus observed&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Dix</span>-<span class="elsevierStyleItalic">Hallpike</span><a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">16</span></a> test &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; is the gold standard&#58; the patient sits on the bed&#44; they turn their head 45&#176; towards the side that is to be tested and then they are put into the supine position&#44; extending their head preferably about 15&#8211;20&#176; below horizontal&#59; this produces movement on the plane of the corresponding posterior canal which enables ampullofugal displacement of the canalith&#46; For a right-sided Dix-Hallpike &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; the right PC is mobilized&#44; and nystagmus is triggered with an upbeating vertical and counter clockwise torsional component &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The nystagmus is disconjugate &#40;since it corresponds to the stimulation of the vertical canals&#41;&#44; the ipsilateral eye shows the torsional component more markedly and the contralateral eye the vertical component&#46; Reference is usually made to how as the gaze moves to the tested side the torsional component increases and when it does so to the contralateral side the vertical component will magnify&#46; However&#44; it is not essential to observe this to make a diagnosis &#40;it is a further characteristic of the eye movements triggered by the vertical canals&#44; not something that is inherent to the paroxysmal positional syndrome&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0170" class="elsevierStylePara elsevierViewall">Nystagmus is preceded by a latency period &#40;varying between 1 and 4<span class="elsevierStyleHsp" style=""></span>s and less than 10<span class="elsevierStyleHsp" style=""></span>s&#41;&#44; it has a paroxysmal course and its duration is less than a minute&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">When the patient is seated upright until the starting position&#44; reverse displacement of the canalith &#40;ampullopetal flow&#41; occurs and with it vertical downbeating and clockwise torsional nystagmus&#44; which is less intense &#40;Ewald&#39;s third law&#58; Ampullofugal flow produces a stronger response than ampullopetal flow in the vertical canals&#41;&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The same Dix-Hallpike will be used to test the left PC&#44; but this time turning the head 45&#176; to the left&#46; The nystagmus&#44; triggered in this case by stimulation of the left PC&#44; will be upbeating vertical and clockwise torsional&#44; also disconjugate&#44; more torsional in the left eye and more vertical in the right &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; When we sit the patient upright it will be possible to observe a reverse&#44; less intense&#44; downbeating&#44; counter clockwise torsional nystagmus&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">It can be difficult to perform a Dix-Hallpike with some patients&#44; generally due to limitations in extending the head&#46; An alternative with the same diagnostic value&#44; that also makes a movement in the plane of the posterior canal&#44; is called the <span class="elsevierStyleItalic">side lying test</span> or <span class="elsevierStyleItalic">Semont test</span><a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">17</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; The patent is seated at the edge of the bed&#44; to examine the right PC their head will be turned 45&#176; to the left to then lie them down on their right side&#59; once the nystagmus has stopped&#44; the patient is sat upright&#46; To examine the left side&#44; the patient&#39;s head is turned to the right and they are placed lying on their left side&#46; The nystagmuses that occur&#44; and their characteristics will be the same as in the Dix-Hallpike tests&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">The characteristics of the nystagmuses observed in each diagnostic test are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Treatment</span><p id="par0195" class="elsevierStylePara elsevierViewall">Treatment of PSC-BPPV is based on particle relocation manoeuvres&#46; As a rule&#44; pharmacological treatment is not useful in resolving BPPV&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The 2 most widely used manoeuvres&#44; and with the most consensus in the literature&#44; with enough class A studies&#44; are the Epley and Semont manoeuvres&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">The Epley manoeuvre was described in 1992&#44;<a class="elsevierStyleCrossRef" href="#bib0650"><span class="elsevierStyleSup">11</span></a> and its generalized use was a turning point in the treatment of BPPV&#46; It seeks to redirect the otoconia from the posterior semi-circular canal to the vestibule through a series of positions that favour their displacement assisted by gravity&#46; The steps to perform the manoeuvre are detailed in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0210" class="elsevierStylePara elsevierViewall">The Semont manoeuvre<a class="elsevierStyleCrossRef" href="#bib0655"><span class="elsevierStyleSup">12</span></a> seeks to achieve sudden displacement of the otoconia from the posterior semi-circular canal to the utricle&#46; The mechanism for performing the test is shown in <a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">In both tests the onset of an &#8220;orthotropic&#8221; nystagmus is a sign of good prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0685"><span class="elsevierStyleSup">18&#44;19</span></a> This is a nystagmus in the second step of the manoeuvres &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3d and 4d</a>&#41;&#44; of the same characteristics in terms of direction and sense as that triggered in their initial position&#46; The presence of this nystagmus will show correct displacement of the otoconia the length of the canal in the direction of the utricle and will increase the likelihood that the manoeuvre will be successful&#59; however&#44; its absence does not absolutely discount the efficacy of the manoeuvre&#46; In contrast&#44; in the Epley manoeuvre&#44; the presence of a reverse nystagmus &#40;non-orthotropic&#41; in this second position is an indicator of the probable failure of the manoeuvre&#46;<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">20</span></a> Therefore it is advisable to monitor eye movements during the repositioning manoeuvres&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Both the Semont and the Epley manoeuvres have proved highly effective in resolving PSC-BPPV&#44;<a class="elsevierStyleCrossRef" href="#bib0700"><span class="elsevierStyleSup">21</span></a> with a similar recurrence rate&#46;<a class="elsevierStyleCrossRefs" href="#bib0705"><span class="elsevierStyleSup">22&#44;23</span></a> Some authors advocate the use of one over the other&#44; and protocols have even been proposed for their combined and sequential use&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">24</span></a> However&#44; none of these strategies has proven clearly superior&#46; Therefore&#44; the choice of manoeuvre fundamentally depends on the experience of the clinician and possibly on any anatomical difficulties the patient might have for a particular manoeuvre to be performed &#40;severe obesity&#44; spinal rigidity&#44; etc&#46;&#41;&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The classical recommendations after a manoeuvre&#44; such as avoiding lying towards the treated side&#44; sleeping in a semi-seated position and wearing a cervical collar have not been shown to increase the efficacy of the manoeuvres enough to recommend them&#46;<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">25</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">BPPV is considered resolved when nystagmus is not observed in the relevant provocation test&#46;</span><a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">6</span></a> The problem of when this check should be made has not yet been solved&#46; If it is performed immediately it can result in false negatives&#44; because the particles will have dispersed after the therapeutic manoeuvre&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">6</span></a> And moreover&#44; if the test is performed immediately it is more likely that re-entry or reflux of the particles to another canal will occur&#46;<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">26</span></a> On the other hand&#44; if left for long periods&#44; we might interpret a spontaneous resolution as the efficacy of the therapeutic manoeuvre<a class="elsevierStyleCrossRefs" href="#bib0700"><span class="elsevierStyleSup">21&#44;27&#44;28</span></a> or a recurrence as &#8220;non-resolution&#8221;&#46;<a class="elsevierStyleCrossRefs" href="#bib0700"><span class="elsevierStyleSup">21&#44;22&#44;29&#44;30</span></a></p><p id="par0235" class="elsevierStylePara elsevierViewall">There are many protocols on how to approach the treatment of BPPV&#59; from performing a single manoeuvre per session and separate sessions over several days to 1 week or repeating the manoeuvres in a single session until the BPPV resolves&#46;<a class="elsevierStyleCrossRefs" href="#bib0685"><span class="elsevierStyleSup">18&#44;23&#44;26&#44;31&#8211;39</span></a> The use of one manoeuvre per session and reviewing the results after 1 week is most frequently described in the literature&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Horizontal Canal Benign Paroxysmal Positional Vertigo</span><p id="par0240" class="elsevierStylePara elsevierViewall">There are 2 acknowledged variants of HC-BPPV&#44; canalithiasis and cupulolithiasis&#44; although the former is more common&#46;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">1&#44;3</span></a> In turn&#44; there are considered to be two subvariants of canalithiasis&#44; depending on whether the particles are in the posterior or anterior arm of the canal&#46;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">1&#44;40&#8211;42</span></a> Therefore&#44; we will refer to 3 different types of HC-BPPV&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0245" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Canalithiasis of the posterior arm</span> &#40;routinely referred to as the geotropic variant in the literature&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0250" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Canalithiasis of the anterior arm</span> &#40;usually included in the literature within the so-called ageotropic variant&#44; although not always specified as canalithiasis&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0255" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cupulolithiasis</span> &#40;ageotropic variant in the literature&#41;&#46;</p></li></ul></p><p id="par0260" class="elsevierStylePara elsevierViewall">Each of the variants have a different pathophysiological behaviour that will condition diagnosis and treatment&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Diagnosis</span><p id="par0265" class="elsevierStylePara elsevierViewall">One of the problems with the horizontal canal is that the diagnostic tests act on both 2 horizontal semi-circular canals at the same time&#44; making it difficult to determine the affected side&#44; which is essential for planning treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0795"><span class="elsevierStyleSup">40</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Pagnini-McClure or roll test</span> is the diagnostic provocation test for the HC&#46;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">1&#44;3</span></a> It is performed with the patient in a supine position and&#44; ideally with their head bent 30&#176; so that the plane of the 2 horizontal canals is vertical&#46;</p><p id="par0275" class="elsevierStylePara elsevierViewall">From the starting supine position the head is turned about 90&#176; to each side&#44; it is strongly recommended to go through the supine position between each lateralization&#46;<a class="elsevierStyleCrossRefs" href="#bib0680"><span class="elsevierStyleSup">17&#44;42</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Horizontal nystagmus</span> is triggered in canalithiasis&#44; with a brief latency &#40;no more than 10<span class="elsevierStyleHsp" style=""></span>s&#41;&#44; of a <span class="elsevierStyleItalic">crescendo-decrescendo</span> course&#44; and duration of less than a minute&#44; which is<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">1&#44;43&#44;44</span></a>&#58;</p><p id="par0285" class="elsevierStylePara elsevierViewall">Posterior arm canalithiasis &#40;geotropic variant&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><p id="par0290" class="elsevierStylePara elsevierViewall">Right horizontal nystagmus when the head is turned to the right&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><p id="par0295" class="elsevierStylePara elsevierViewall">Left horizontal nystagmus when the head is turned to the left&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0305" class="elsevierStylePara elsevierViewall">Anterior arm canalithiasis &#40;ageotropic variant&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0030"><p id="par0310" class="elsevierStylePara elsevierViewall">Left horizontal nystagmus when the head is turned to the right&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><p id="par0315" class="elsevierStylePara elsevierViewall">Right horizontal nystagmus when the head is turned to the left&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0325" class="elsevierStylePara elsevierViewall">Since this is canalithiasis&#44; each time the head changes position the particles are displaced according to the gravity vector&#46; Therefore&#44; when going from the lateral decubitus position to the supine position a reverse nystagmus can be observed to that obtained in the previous turn of the head and therefore differs going from a right turn to a left turn&#46; Observation of this nystagmus &#40;which will have a latency and will last for less than a minute&#41; might be very useful in confirming canalithiasis&#46;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0040"><p id="par0330" class="elsevierStylePara elsevierViewall">In <span class="elsevierStyleItalic">cupulolithiasis</span> &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#44; with the head-roll manoeuvre&#44; a horizontal nystagmus occurs&#44; with no latency&#44; and which persists while in the position&#44; which will be<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">1&#44;43&#44;44</span></a>&#58;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0045"><p id="par0335" class="elsevierStylePara elsevierViewall">Left horizontal nystagmus when the head is turned towards the right&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><p id="par0340" class="elsevierStylePara elsevierViewall">Right horizontal nystagmus when the head is turned towards the left&#46;</p></li></ul></p><p id="par0345" class="elsevierStylePara elsevierViewall">Given the spatial orientation of the HC ampulla&#44; in the supine decubitus position the cupula is not aligned with the vertical&#44; but slightly in an ampullopetal direction&#46;<a class="elsevierStyleCrossRef" href="#bib0820"><span class="elsevierStyleSup">45</span></a> Therefore&#44; it is usual to observe a horizontal nystagmus in the supine decubitus position beating towards the affected side &#40;right if the right ear is affected and left if the left ear is affected&#41;&#46; Because the particles adhere to the cupula and are not mobile within the canal&#44; in the supine decubitus position the nystagmus will always beat in the same direction&#44; whatever the position of the previous lateral turn&#46; This nystagmus&#44; with the same pathophysiological basis&#44; can also be seen with the patient in a seated position&#44; and is usually termed <span class="elsevierStyleItalic">spontaneous pseudonystagmus&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0825"><span class="elsevierStyleSup">46&#44;47</span></a></p><p id="par0350" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Determination of the affected side</span> in any of the 3 variants of HC-BPPV is based on Ewald&#39;s second law&#58; in the HC the ampullopetal deflections generate more intense nystagmus than the ampullofugal deflections&#46;<a class="elsevierStyleCrossRefs" href="#bib0795"><span class="elsevierStyleSup">40&#44;48</span></a> Therefore&#44; we believe that is it is more appropriate to refer to the direction of the nystagmus triggered than to the position of the head when it is generated&#46; Thus&#44; for any of the variants&#44; it can be said that the <span class="elsevierStyleItalic">rapid phase of the most intense nystagmus will indicate the affected side</span>&#46; Therefore&#44; we recommend that movements of the head to either side should be of similar amplitude and that each lateral turn should pass through the supine position&#46; It is also important for diagnostic purposes that the movements are not very sudden&#44; as this could add a component of inertia&#44; especially in canalithiasis&#44; which would alter the anticipated direction of the particle displacement&#44; reversing the expected nystagmus and creating confusion in establishing a diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0680"><span class="elsevierStyleSup">17&#44;49</span></a></p><p id="par0355" class="elsevierStylePara elsevierViewall">Where there is any doubt&#44; we recommend complementing the provocation test with the <span class="elsevierStyleItalic">flexion and extension manoeuvre</span> &#40;<span class="elsevierStyleItalic">termed the Bow and Lean manoeuvre in the literature</span>&#41;<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRefs" href="#bib0805"><span class="elsevierStyleSup">42&#44;50&#8211;55</span></a> This test is not based on estimating the intensity of the nystagmus triggered&#44; but rather on its direction&#44; which is due to the spatial layout of the horizontal canals and their alignment with the gravity vector in the flexion and extension movements of the head&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall">Canalithiasis of the posterior arm of the HC &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0055"><p id="par0365" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Flexion&#58;</span> horizontal nystagmus towards the affected side &#40;there will be ampullopetal displacement of the particles&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><p id="par0370" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Extension&#58;</span> horizontal nystagmus beating towards the healthy side &#40;there will be ampullofugal displacement of the particles&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0065"><p id="par0375" class="elsevierStylePara elsevierViewall">Therefore&#44; the affected side will be indicated by the direction of the nystagmus on flexion&#46;</p></li></ul></p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0380" class="elsevierStylePara elsevierViewall">Canalithiasis of the anterior arm &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0070"><p id="par0385" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Flexion</span>&#58; horizontal nystagmus beating towards the healthy side &#40;ampullofugal displacement of the particles&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><p id="par0390" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Extension</span>&#58; horizontal nystagmus beating towards the affected side &#40;ampullopetal displacement of the particles&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><p id="par0395" class="elsevierStylePara elsevierViewall">Therefore&#44; the affected side will be indicated by the direction of the nystagmus obtained on extension&#46;</p></li></ul></p><p id="par0400" class="elsevierStylePara elsevierViewall">Cupulolithiasis &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#58;<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0085"><p id="par0405" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Flexion</span>&#58; horizontal nystagmus beating towards the healthy side &#40;the ampulla of the canal will tilt ampullifugally&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><p id="par0410" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Extension</span>&#58; horizontal nystagmus beating towards the affected side &#40;the ampulla of the canal will tilt ampullipetally&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><p id="par0415" class="elsevierStylePara elsevierViewall">Therefore&#44; the affected side will be indicated by the direction of the nystagmus obtained on extension&#46;</p></li></ul></p><p id="par0420" class="elsevierStylePara elsevierViewall">It is not unusual to find horizontal positional nystagmus in patients with diverse vestibular disorders &#40;not positional paroxysmal&#41;&#44; but they must meet the abovementioned criteria of latency&#44; direction change&#44; duration&#44; etc&#46; to make a specific diagnosis of HC-BPPV&#46;<a class="elsevierStyleCrossRef" href="#bib0875"><span class="elsevierStyleSup">56</span></a> In this regard&#44; 2 entities have recently been described that are not BPPV&#44; and that would be associated with alterations in the density of endolymph or of the cupulas&#46;<a class="elsevierStyleCrossRef" href="#bib0880"><span class="elsevierStyleSup">57</span></a> These are termed light cupula and heavy cupula syndromes&#44; which would not be caused by the presence of extemporaneous particles&#46; In the case of a light cupula&#44; exploration using the Pagnini-McClure test would show horizontal nystagmus similar to posterior arm canalithiasis&#44; but there would be no latency or paroxysmal composition and the nystagmus would be persistent&#46;<a class="elsevierStyleCrossRefs" href="#bib0805"><span class="elsevierStyleSup">42&#44;43&#44;53&#44;55&#44;58&#8211;61</span></a> In the case of a heavy cupula&#44; exploration would be similar in all ways to that of an HC cupulolithiasis&#59; the fact that it is not a cupulolithiasis could explain the lack of response to therapeutic manoeuvres&#46;<a class="elsevierStyleCrossRefs" href="#bib0800"><span class="elsevierStyleSup">41&#44;52&#44;54&#44;57&#44;61</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Treatment</span><p id="par0425" class="elsevierStylePara elsevierViewall">Many manoeuvres and variants for the treatment of HC-BPPV have been described&#44; but few clinical trials and systematic reviews &#40;Class I and II studies&#41;&#44; so that meta-analysis cannot be used either as a tool to help discern the best treatment for those that have been described&#46; And neither is there uniformity in how the manoeuvres are termed or described&#46;</p><p id="par0430" class="elsevierStylePara elsevierViewall">Based on class I or II studies&#44; we will only consider the Gufoni and barbecue roll &#40;or Lempert&#41; manoeuvres&#46;</p><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Treatment of Posterior Arm Canalithiasis &#40;Geotropic Variant&#41;</span><p id="par0435" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Gufoni&#39;s manoeuvre</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#44; also termed Gufoni&#39;s manoeuvre for the geotropic variant<a class="elsevierStyleCrossRefs" href="#bib0605"><span class="elsevierStyleSup">2&#44;3&#44;46&#44;62&#8211;67</span></a>&#58; starting with the subject seated on the edge of the bed&#44; <span class="elsevierStyleItalic">they are then laid down on their healthy side</span>&#46; When the nystagmus disappears &#40;or after 60&#8211;90<span class="elsevierStyleHsp" style=""></span>s&#41; the head is turned 45&#176; towards the healthy side &#40;nose towards the bed&#41;&#46; When the nystagmus ceases or after 60&#8211;90<span class="elsevierStyleHsp" style=""></span>s&#44; the patient is sat upright&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0440" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Lempert or BBQ roll manoeuvre</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0030">Fig&#46; 6</a>&#41;<a class="elsevierStyleCrossRefs" href="#bib0605"><span class="elsevierStyleSup">2&#44;46&#44;64&#44;65&#44;68&#44;69</span></a>&#58; starting with the patient in a supine decubitus position&#44; their head is turned 90&#176; towards the healthy side&#46; In phases set by the duration of the nystagmus &#40;or periods of 60&#8211;90<span class="elsevierStyleHsp" style=""></span>s&#41; turns of 90&#176; are made &#40;gradually including the body as the head turns&#41; until the patient is on the affected side &#40;270&#176;&#41; and then they are sat upright&#46;</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Treatment of Anterior Arm Canalithiasis</span><p id="par0445" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Gufoni manoeuvre for the ageotropic variant</span>&#44; also termed <span class="elsevierStyleItalic">Appiani manouevre</span><a class="elsevierStyleCrossRefs" href="#bib0945"><span class="elsevierStyleSup">70&#44;71</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#58; starting with the patient seated on the edge of the bed&#44; <span class="elsevierStyleItalic">they are then laid on their affected side</span>&#46; After the nystagmus disappears &#40;or after 60&#8211;90<span class="elsevierStyleHsp" style=""></span>s&#41; their head is turned 45&#176; towards their healthy side &#40;nose upwards&#41;&#46; After the nystagmus disappears the patient is sat upright&#46; The BPPV can resolve with this manoeuvre or the particles might only move to the posterior part of the canal&#46; In this case&#44; the treatment will have to be completed by giving appropriate treatment for this variant&#46;</p><elsevierMultimedia ident="fig0035"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Treatment of Cupulolithiasis</span><p id="par0450" class="elsevierStylePara elsevierViewall">The same treatment as that for anterior arm canalithiasis will be used &#40;<span class="elsevierStyleItalic">Gufoni manoeuvre for ageotropic variant&#47;Appiani manoeuvre</span>&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0945"><span class="elsevierStyleSup">70&#44;71</span></a> with longer times between the different positions &#40;<a class="elsevierStyleCrossRef" href="#fig0035">Fig&#46; 7</a>&#41;&#46; Here we would also expect to convert it initially to a posterior arm canalithiasis&#44; once the particles are released from the cupula&#44; and proceed to complete the treatment with the appropriate manoeuvres&#46;</p><p id="par0455" class="elsevierStylePara elsevierViewall">A variant of the barbecue manoeuvre has been described for anterior arm canalithiasis and cupulolithiasis&#44; with an earlier stage in which the head is turned towards the affected side<a class="elsevierStyleCrossRefs" href="#bib0955"><span class="elsevierStyleSup">72&#44;73</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0040">Fig&#46; 8</a>&#41;&#46;</p><elsevierMultimedia ident="fig0040"></elsevierMultimedia><p id="par0460" class="elsevierStylePara elsevierViewall">HC-BPPV is considered resolved when no nystagmus is triggered after the provocation tests&#46;</p></span></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Probable Benign Paroxysmal Positional Vertigo&#44; Spontaneously Resolved</span><p id="par0465" class="elsevierStylePara elsevierViewall">An absence of nystagmus with the provocation tests in a patient with symptoms suggestive of BPPV does not rule out its diagnosis&#44; since it is possible that there is an insufficient number of particles to generate positional nystagmus&#46; This situation is common in clinical practice and is termed probable BPPV&#44; spontaneously resolved&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Anterior Canal Canalithiasis</span><p id="par0470" class="elsevierStylePara elsevierViewall">The AC is least frequently affected &#40;3&#37; of BPPV&#41;&#44; which is easy to explain given its orientation&#46;<a class="elsevierStyleCrossRefs" href="#bib0965"><span class="elsevierStyleSup">74&#44;75</span></a> There are few current series with few cases&#44; therefore there are no class I or II studies on which to base the diagnosis and treatment of AC canalithiasis&#46; It is controversial to an extent&#44; and the B&#225;r&#225;ny Society classification includes it in the emerging BPPV syndromes&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">1</span></a></p><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Diagnosis</span><p id="par0475" class="elsevierStylePara elsevierViewall">AC canalithiasis would be diagnosed by the <span class="elsevierStyleItalic">cephalic hyperextension</span> or <span class="elsevierStyleItalic">Dix-Hallpike</span> test &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0975"><span class="elsevierStyleSup">76&#8211;78</span></a> All of these show up nystagmus corresponding to ampullifugal stimulation of the affected AC&#46; As in canalithiasis of all types&#44; the nystagmus is paroxysmal&#44; it has a latency of no more than 10<span class="elsevierStyleHsp" style=""></span>s and a maximum duration of 1<span class="elsevierStyleHsp" style=""></span>min&#46; It is essentially downbeating with a torsional component&#44; often difficult to appreciate &#40;especially by the naked eye&#41;&#44; which is clockwise for left AC and counter clockwise for right AC &#40;<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>&#41;&#46; Although it is difficult to identify&#44; the torsional component would be the indicator of the affected side&#44; as in both the cephalic hyperextension test and the 2 Dix-Hallpike tests&#44; right and left&#44; the 2 anterior canals are stimulated &#40;<a class="elsevierStyleCrossRef" href="#fig0045">Fig&#46; 9</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">10</span></a> When the patient is sat upright&#44; reverse nystagmus can be seen &#40;upbeating and counter clockwise if it is left&#44; and clockwise if right&#41;&#46;</p><elsevierMultimedia ident="fig0045"></elsevierMultimedia><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><p id="par0480" class="elsevierStylePara elsevierViewall">Persistent downbeating nystagmus is mentioned in the literature &#40;of a duration longer than a minute&#41; and attributed to cupulolithiasis of the anterior canal&#44; but this entity&#44; although possible&#44; cannot yet be considered proven&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Treatment</span><p id="par0485" class="elsevierStylePara elsevierViewall">Many treatment variants have been speculated&#44; generally developed from treatments of posterior canal BPPV&#44; which would be partially or fully reversed&#46;<a class="elsevierStyleCrossRefs" href="#bib0980"><span class="elsevierStyleSup">77&#44;79&#8211;82</span></a> The <span class="elsevierStyleItalic">Yacovino manouevre</span>&#44;<a class="elsevierStyleCrossRef" href="#bib1010"><span class="elsevierStyleSup">83</span></a> has become particularly popular&#44; which has the advantage of not requiring the affected side to be identified&#44; since it would treat either of the 2 AC &#40;<a class="elsevierStyleCrossRef" href="#fig0050">Fig&#46; 10</a>&#41;&#46;</p><elsevierMultimedia ident="fig0050"></elsevierMultimedia></span></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Posterior Canal Cupulolithiasis</span><p id="par0490" class="elsevierStylePara elsevierViewall">There are few described cases and there are no series available to study&#46;</p><p id="par0495" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Diagnosis</span> would be based on the <span class="elsevierStyleItalic">Dix-Hallpike test&#46;</span> The nystagmus obtained would be in the same direction and sense as for canalithiasis&#44; but with no latency and lasting for the time the position is maintained&#46; If&#44; after the Dix-Hallpike with the patient&#39;s head still turned 45&#176; towards the side to be explored&#44; we bend the head 90&#176; &#40;<span class="elsevierStyleItalic">reverse Dix-Hallpike</span>&#41;&#44; a reverse nystagmus will be triggered&#44; which is also persistent and without latency&#44; and of less intensity&#46;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">1&#44;6&#44;84</span></a> In summary&#58;</p><p id="par0500" class="elsevierStylePara elsevierViewall">Right PC cupulolithiasis&#58;<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0100"><p id="par0505" class="elsevierStylePara elsevierViewall">Right Dix-Hallpike&#58; upbeating and counter clockwise nystagmus&#44; persistent without latency&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><p id="par0510" class="elsevierStylePara elsevierViewall">Right reverse Dix-Hallpike&#58; downbeating and clockwise nystagmus&#44; persistent and without latency&#46;</p></li></ul></p><p id="par0515" class="elsevierStylePara elsevierViewall">Left PC cupulolithiasis&#58;<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0110"><p id="par0520" class="elsevierStylePara elsevierViewall">Left Dix-Hallpike&#58; upbeating and clockwise nystagmus&#44; persistent and without latency&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><p id="par0525" class="elsevierStylePara elsevierViewall">Left reverse Dix-Hallpike&#58; inferior and counter clockwise nystagmus&#44; persistent and without latency&#46;</p></li></ul></p><p id="par0530" class="elsevierStylePara elsevierViewall">Treatment can be given with the Semont or Epley manoeuvre&#46; The Semont manoeuvre &#40;more sudden&#41; would be expected to give better results for patients with cupulolithiasis&#44; since it would release the otoconia from the cupula&#46;<a class="elsevierStyleCrossRefs" href="#bib0655"><span class="elsevierStyleSup">12&#44;13</span></a> However&#44; it has not been possible to demonstrate this&#46;</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Benign Paroxysmal&#44; Positional Vertigo With Involvement of Multiple Canals</span><p id="par0535" class="elsevierStylePara elsevierViewall">This is included in the B&#225;r&#225;ny Society as an emerging diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">1</span></a> It is considered that it might be underdiagnosed and would be more common in cases of posttraumatic BPPV&#46; The combination that is most frequently described is of the posterior and horizontal canals of a labyrinth&#44; although any combination would be possible&#46;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">1&#44;85&#8211;87</span></a></p><p id="par0540" class="elsevierStylePara elsevierViewall">The clinical symptoms would be appropriate for the syndrome and on examination there would be more than one positive diagnostic positional test&#44; with the characteristics described for the relevant canal&#44; although nystagmus corresponding to the other affected canal or canals&#44; total or partially overlapping&#44; might affect the diagnosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">1&#44;10&#44;86&#44;87</span></a></p><p id="par0545" class="elsevierStylePara elsevierViewall">We must bear in mind that&#44; whatever the test used&#44; the remaining canals &#40;those not specifically explored&#41; will not stay perpendicular to the force of gravity&#44; so that any particles present in them might displace&#46;<a class="elsevierStyleCrossRefs" href="#bib0645"><span class="elsevierStyleSup">10&#44;75&#44;88&#44;89</span></a> Therefore&#44; for example&#44; when a Dix-Hallpike test is performed&#44; the displacement of a particle in the posterior as well as the anterior canal might be triggered &#40;as has been seen when referring specifically to its canalithiasis&#41;&#46; Therefore&#44; it is necessary always to describe all the features of nystagmus&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Refractory Benign Paroxysmal Positional Vertigo&#58; Persistent and Recurrent Benign Paroxysmal Positional Vertigo</span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Persistent Benign Paroxysmal Positional Vertigo</span><p id="par0550" class="elsevierStylePara elsevierViewall">Partial repositioning manoeuvres are very effective especially for the posterior canal&#44; where it is estimated that 90&#37;&#8211;95&#37; of cases are resolved with an average of one to 3 manouevres&#46;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">6&#44;21&#44;23&#44;34&#44;37&#44;90&#8211;93</span></a> This resolution rate is lower for the HC &#40;85&#37;&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0740"><span class="elsevierStyleSup">29&#44;34&#44;65&#44;71&#44;90&#44;94</span></a> and is difficult to calculate&#44; due to the few case studies for SC&#46;</p><p id="par0555" class="elsevierStylePara elsevierViewall">However&#44; there are patients &#40;3&#46;5&#37;&#8211;12&#37;&#44; depending on the series&#41;<a class="elsevierStyleCrossRefs" href="#bib1070"><span class="elsevierStyleSup">95&#8211;97</span></a> whose symptoms and nystagmus persist despite repeating the manoeuvres&#46;</p><p id="par0560" class="elsevierStylePara elsevierViewall">It is always necessary to confirm a diagnosis&#44; excluding causes of positional vertigo other than BPPV&#46;<a class="elsevierStyleCrossRefs" href="#bib1075"><span class="elsevierStyleSup">96&#44;97</span></a> Once a diagnosis of BPPV has been confirmed&#44; various therapeutic possibilities have been described for the PC&#58;<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8226;</span><p id="par0565" class="elsevierStylePara elsevierViewall">Habituation exercises&#44; those proposed by Brandt and Daroff<a class="elsevierStyleCrossRef" href="#bib1085"><span class="elsevierStyleSup">98</span></a> being the prototype&#46; Brandt and Daroff&#39;s exercises have proven less effective in resolving PC-BPPV than the particle repositioning manouevres&#44;<a class="elsevierStyleCrossRefs" href="#bib0715"><span class="elsevierStyleSup">24&#44;31</span></a> but they might play a role for patients for whom these manoeuvres have failed&#46; They have two objectives&#58; the dispersion and disaggregation of otoconia&#44; repeatedly moving them in the canal&#44; and promoting central habituation mechanisms&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8226;</span><p id="par0570" class="elsevierStylePara elsevierViewall">Surgical intervention<a class="elsevierStyleCrossRefs" href="#bib1090"><span class="elsevierStyleSup">99&#44;100</span></a>&#58; singular nerve section or occlusion of the posterior semi-circular canal&#46; Reserved for patients who are completely refractory to treatment and those whose symptoms are significantly limiting their quality of life&#46;</p></li></ul></p><p id="par0575" class="elsevierStylePara elsevierViewall">New proposals are also being developed&#44; such as methylprednisolone injection adjuvant to repositioning manouevres&#46;<a class="elsevierStyleCrossRef" href="#bib1100"><span class="elsevierStyleSup">101</span></a></p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Recurrent Benign Paroxysmal Positional Vertigo</span><p id="par0580" class="elsevierStylePara elsevierViewall">Whatever the therapeutic manoeuvre used&#44; a recurrence percentage has been reported that increases as the follow-up period increases&#44; even nearing 50&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0745"><span class="elsevierStyleSup">30&#44;90&#44;102&#44;103</span></a> Two studies performed in our environment<a class="elsevierStyleCrossRefs" href="#bib0705"><span class="elsevierStyleSup">22&#44;23</span></a> report a recurrence rate of around 25&#37;&#44; the most frequent being in the first 6&#8211;12 months after performing the therapeutic manoeuvre&#46; These recurrences can occur in a different canal and&#47;or in the contralateral ear to that of the first BPPV episode&#46;</p><p id="par0585" class="elsevierStylePara elsevierViewall">The treatment does not vary&#44; and the repositioning manoeuvre will be performed for the ear affected by the recurrence&#46;</p></span></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Differential Diagnosis of Benign Paroxysmal Positional Vertigo</span><p id="par0590" class="elsevierStylePara elsevierViewall">The disorders that could be confused with BPPV can be grouped into 3 categories&#58; otological&#44; neurological and other entities &#40;<a class="elsevierStyleCrossRefs" href="#tbl0035">Tables 7&#8211;9</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0610"><span class="elsevierStyleSup">3&#44;17</span></a></p><elsevierMultimedia ident="tbl0035"></elsevierMultimedia><elsevierMultimedia ident="tbl0040"></elsevierMultimedia><elsevierMultimedia ident="tbl0045"></elsevierMultimedia><p id="par0595" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">otological diseases</span> include Meniere&#39;s disease&#44; acute unilateral vestibular syndrome &#40;neuritis&#44; labyrinthitis&#41;&#44; superior semi-circular canal dehiscence&#44; dilated vestibular aqueduct and perilymphatic fistula&#46;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">1&#44;3&#44;17&#44;104&#44;105</span></a></p><p id="par0600" class="elsevierStylePara elsevierViewall">Although exploration using positional tests confirms diagnosis&#44; the basic clinical features &#40;trigger of the episodes&#44; their duration and associated hearing loss&#41; can be very helpful in making a differential diagnosis &#40;<a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>&#41;&#46;</p><p id="par0605" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">neurological processes</span> that can simulate a BPPV are detailed in <a class="elsevierStyleCrossRef" href="#tbl0040">Table 8</a>&#46;<a class="elsevierStyleCrossRefs" href="#bib0600"><span class="elsevierStyleSup">1&#44;3&#44;14&#44;17&#44;106&#8211;109</span></a></p><p id="par0610" class="elsevierStylePara elsevierViewall">There is a series of warning signs on examination that can indicate the presence of a paroxysmal positional vertigo of central origin&#44; such as<a class="elsevierStyleCrossRef" href="#bib1140"><span class="elsevierStyleSup">109</span></a>&#58;<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">&#8226;</span><p id="par0615" class="elsevierStylePara elsevierViewall">The presence of signs or symptoms of CNS disease &#40;such as gaze-evoked nystagmus&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">&#8226;</span><p id="par0620" class="elsevierStylePara elsevierViewall">Absence of nystagmus reversal when the position is reversed&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">&#8226;</span><p id="par0625" class="elsevierStylePara elsevierViewall">Marked position-induced hyperemesis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">&#8226;</span><p id="par0630" class="elsevierStylePara elsevierViewall">A direction of nystagmus that does not correspond to the canal explored by the manoeuvre&#44; especially in the following cases&#58;<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">&#8728;</span><p id="par0635" class="elsevierStylePara elsevierViewall">Persistent vertical positional down-beating nystagmus and with no torsional component&#46;</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">&#8728;</span><p id="par0640" class="elsevierStylePara elsevierViewall">Nystagmus taking different directions in diagnostic manoeuvres performed on repeated occasions &#40;as long as repositioning manoeuvres have not been performed&#44; because in that case the particles might have moved from one canal to another&#41;&#46;</p></li></ul></p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">&#8226;</span><p id="par0645" class="elsevierStylePara elsevierViewall">Nystagmus of changing direction without changes of head position&#46;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">&#8226;</span><p id="par0650" class="elsevierStylePara elsevierViewall">Onset of nystagmus when the patient is asked to hold their gaze &#40;<span class="elsevierStyleItalic">gaze holding nystagmus</span>&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">&#8226;</span><p id="par0655" class="elsevierStylePara elsevierViewall">Spontaneous nystagmus with no positional manoeuvres &#40;discounting the positional pseudonystagmus of HC-BPPV&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">&#8226;</span><p id="par0660" class="elsevierStylePara elsevierViewall">Nystagmus with no dizziness in positional tests&#46;</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">&#8226;</span><p id="par0665" class="elsevierStylePara elsevierViewall">Poor response to therapeutic manoeuvres&#46;</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">&#8226;</span><p id="par0670" class="elsevierStylePara elsevierViewall">Multiple recurrences confirmed with diagnostic manoeuvres&#46;</p></li></ul></p><p id="par0675" class="elsevierStylePara elsevierViewall">We must bear in mind that there is an association between BPPV and other vestibular disorders such as Meniere&#39;s disease&#44; vestibular neuritis and migraine&#46; Therefore&#44; if a patient has specific symptoms&#44; we should consider the possibility of their having more than one vestibular disorder simultaneously&#46;<a class="elsevierStyleCrossRefs" href="#bib1145"><span class="elsevierStyleSup">110&#8211;113</span></a></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Imaging Tests for Benign Paroxysmal Positional Vertigo</span><p id="par0680" class="elsevierStylePara elsevierViewall">Imaging tests are not necessary to diagnose BPPV &#40;level of evidence C according to the clinical practice guideline of the American Academy of Otolaryngology&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">3</span></a></p><p id="par0685" class="elsevierStylePara elsevierViewall">Brain MRI is generally indicated if central disease is suspected&#44; as in the following cases<a class="elsevierStyleCrossRef" href="#bib1140"><span class="elsevierStyleSup">109</span></a>&#58;<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">1&#41;</span><p id="par0690" class="elsevierStylePara elsevierViewall">Signs or symptoms of brainstem and&#47;or cerebellar dysfunction&#46;</p></li><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">2&#41;</span><p id="par0695" class="elsevierStylePara elsevierViewall">Vertigo and positional nystagmus that are not compatible with stimulation of any canal in particular&#46;</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">3&#41;</span><p id="par0700" class="elsevierStylePara elsevierViewall">Persistent BPPV&#46;</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">4&#41;</span><p id="par0705" class="elsevierStylePara elsevierViewall">Recurrent BPPV on at least 3 occasions confirmed by the appropriate positional tests&#46;</p></li></ul></p><p id="par0710" class="elsevierStylePara elsevierViewall">Horizontal positional nystagmuses are frequently found in clinical practice that do not fulfil the criteria of HC-BPPV&#44; as well as persistent down-beating vertical nystagmuses with no torsional component&#44; for which MRI would be indicated &#40;within a cerebral infarction screening programme&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib1160"><span class="elsevierStyleSup">113</span></a> But it is relatively common not to find lesions on imaging tests&#44; particularly in the case of down-beating vertical nystagmus&#44; which makes the diagnostic value of MRI questionable when these nystagmuses are the only change found on exploration&#46;<a class="elsevierStyleCrossRefs" href="#bib1185"><span class="elsevierStyleSup">118&#44;119</span></a></p><p id="par0715" class="elsevierStylePara elsevierViewall">This would explain the B&#225;r&#225;ny Society&#39;s inclusion of the term <span class="elsevierStyleItalic">possible BPPV</span> in their classification&#46; Clinically it would be compatible with BPPV&#44; but the nystagmus would not be explained when applying the criteria of each subtype&#46; Once other diseases have been ruled out we might consider it to be a BPPV &#40;multi-canal for example&#41; whose nystagmus we do not know how to interpret&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">1</span></a></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Pharmacological Treatment of Benign Paroxysmal Positional Vertigo</span><p id="par0720" class="elsevierStylePara elsevierViewall">There is no evidence in the literature for drugs that are effective in the definitive treatment of BPPV or that would substitute the therapeutic manoeuvres &#40;level of evidence C according to the clinical practice guidelines of the American Academy of Otolaryngology&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0610"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conflicts of Interest</span><p id="par0725" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare&#46;</p></span></span>"
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          "titulo" => "Canalithiasis of the Posterior Semi-circular Canal"
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                  "titulo" => "Treatment of Cupulolithiasis"
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          "titulo" => "Probable Benign Paroxysmal Positional Vertigo&#44; Spontaneously Resolved"
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              "identificador" => "sec0110"
              "titulo" => "Persistent Benign Paroxysmal Positional Vertigo"
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              "titulo" => "Recurrent Benign Paroxysmal Positional Vertigo"
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          "titulo" => "Differential Diagnosis of Benign Paroxysmal Positional Vertigo"
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          "titulo" => "Imaging Tests for Benign Paroxysmal Positional Vertigo"
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          "titulo" => "Pharmacological Treatment of Benign Paroxysmal Positional Vertigo"
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    "fechaRecibido" => "2017-04-26"
    "fechaAceptado" => "2017-05-04"
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            0 => "V&#233;rtigo posicional parox&#237;stico benigno"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Benign paroxysmal positional vertigo is the most frequent episodic vestibular disorder&#46; The purpose of this guide&#44; requested by the committee on otoneurology of the Spanish Society of Otolaryngology and Head and Neck Surgery&#44; is to supply a consensus document providing practical guidance for the management of BPPV&#46; It is based on the Barany Society criteria for the diagnosis of BPPV&#46; This guideline provides recommendations on each variant of BPPV&#44; with a description of the different diagnostic tests and the therapeutic manoeuvres&#46; For this purpose&#44; we have selected the tests and manoeuvres supported by evidence-based studies or extensive series&#46; Finally&#44; we have also included a chapter on differential diagnosis and a section relating to general aspects in the management of BPPV&#46;</p></span>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El v&#233;rtigo posicional parox&#237;stico benigno &#40;VPPB&#41; es la causa m&#225;s frecuente de v&#233;rtigo vestibular epis&#243;dico&#46; EL prop&#243;sito de esta gu&#237;a&#44; encomendada por la Comisi&#243;n de Otoneurolog&#237;a de la SEORL CCC&#44; es disponer de un documento de consenso que sirva de gu&#237;a pr&#225;ctica para el manejo del VPPB en la cl&#237;nica diaria&#46; El punto de partida es la clasificaci&#243;n elaborada por la Barany Society&#44; con sus variantes cl&#237;nicas&#46; Incluye una descripci&#243;n de las pruebas diagn&#243;sticas y de las maniobras terap&#233;uticas para cada una de las variantes establecidas&#44; habi&#233;ndose seleccionado aquellas con estudios con nivel adecuado de evidencia o con suficientes series de soporte&#46; Se ha incluido tambi&#233;n un cap&#237;tulo de diagn&#243;stico diferencial&#44; as&#237; como un apartado de aspectos generales b&#225;sicos en el manejo de los pacientes con VPPB&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; P&#233;rez-V&#225;zquez P&#44; Franco-Guti&#233;rrez V&#44; Soto-Varela A&#44; Amor-Dorado JC&#44; Mart&#237;n-Sanz E&#44; Oliva-Dom&#237;nguez M&#44; et al&#46; Gu&#237;a de Pr&#225;ctica Cl&#237;nica Para el Diagn&#243;stico y Tratamiento del V&#233;rtigo Posicional Parox&#237;stico Benigno&#46; Documento de Consenso de la Comisi&#243;n de Otoneurolog&#237;a Sociedad Espa&#241;ola de Otorrinolaringolog&#237;a y Cirug&#237;a de Cabeza y Cuello&#46; Acta Otorrinolaringol Esp&#46; 2018&#59;69&#58;345&#8211;366&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Dix-Hallpike test for canalithiasis of the posterior canal &#40;right&#41;&#58; &#40;a&#41; patient seated on the bed&#44; with their head facing forwards&#59; &#40;b&#41; we turn their head approximately 45&#176; towards one of the 2 sides &#40;in this case to the right&#41;&#59; &#40;c&#41; maintaining this head position in relation to the trunk&#44; we lie the patient down&#44; so that their head is approximately 20&#176; below the horizontal&#59; we maintain this position for at least 30<span class="elsevierStyleHsp" style=""></span>s &#40;maximum latency until onset of nystagmus&#41;&#59; &#40;d&#41; we sit the patient upright&#46;</p>"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Lateral decubitus test for canalithiasis of the posterior canal &#40;right&#41;&#58; &#40;a&#41; the patient is seated in the middle of the bed&#44; with their legs hanging down&#59; &#40;b&#41; we turn their head 45&#176; towards the left side&#59; &#40;c&#41; without changing the position of their head in relation to their trunk&#44; we lie the patient down on their right side&#59; we maintain this position for at least 30<span class="elsevierStyleHsp" style=""></span>s &#40;maximum latency until the onset of nystagmus&#41;&#59; &#40;d&#41; we sit the patient upright&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Epley manoeuvre for canalithiasis of the posterior canal &#40;right side&#41;&#58; &#40;a&#41; the patient is seated on the bed&#44; with their head facing forwards&#59; &#40;b&#41; we turn their head approximately 45&#176; to the right&#59; &#40;c&#41; maintaining this head position in relation to the trunk&#44; we lie the patient down&#44; so that their head is approximately 20&#176; below the horizontal&#59; we maintain this position until the nystagmus disappears or for at least 30<span class="elsevierStyleHsp" style=""></span>s&#59; &#40;d&#41; we turn the patient&#39;s head 90&#176; to the left&#44; so that it is rotated 45&#176; to the left in relation to the supine decubitus position&#59; we maintain this position until the nystagmus ceases &#40;if it appears&#41; or at least 30<span class="elsevierStyleHsp" style=""></span>s&#59; &#40;e&#41; we turn the patient&#39;s head and trunk&#44; en bloc&#44; another 90&#176; to the left&#44; so that the head is rotated 135&#176; to the left in relation to the supine decubitus&#59; we maintain this position until the nystagmus ceases &#40;if it appears&#41; or&#44; at least 30<span class="elsevierStyleHsp" style=""></span>s&#59; &#40;f&#41; we sit the patient upright&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Semont manoeuvre for canalithiasis of the posterior canal &#40;right side&#41;&#58; &#40;a&#41; the patient is seated in the middle of the bed&#59; &#40;b&#41; we turn their head 45&#176; towards the left side&#59; &#40;c&#41; without modifying the position of the head in relation to the trunk we quickly lie the patient down on their right side&#59; we maintain this position for 4<span class="elsevierStyleHsp" style=""></span>min&#59; &#40;d&#41; without changing the position of the head in relation to the trunk&#44; we quickly turn the patient 180&#176; so that they are lying on their left side with their face towards the bed&#59; we maintain this position for another 4<span class="elsevierStyleHsp" style=""></span>min&#59; &#40;e&#41; we sit the patient upright&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Gufoni manoeuvre for canalithiasis of the posterior arm of the horizontal canal &#40;left side&#41;&#46; We start with the patient seated on the edge of the bed&#58; &#40;I&#41; we lie the patient down on their health side &#40;in this case the right side&#41;&#59; &#40;II&#41; we turn the patient&#39;s head 45&#176; towards the health side &#40;with their nose facing the bed&#41;&#59; &#40;III&#41; we sit the patient upright&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Lempert or barbecue manoeuvre for canalithiasis of the posterior arm of the horizontal canal &#40;right side&#41;&#46; Starting in the supine decubitus position we gradually turn the patient towards their healthy side&#58; &#40;I&#41; we turn their head towards the healthy side &#40;left in this case&#41;&#59; &#40;II&#41; we turn their body to the left&#59; &#40;III&#41; we turn their head another 45&#176; towards the healthy side &#40;they will be looking downwards&#41;&#59; &#40;IV&#41; we turn the patient&#39;s body to the left&#44; leaving them fully in the prone position&#59; &#40;V&#41; we turn their body 45&#176; towards the left&#59; &#40;VI&#41; we sit the patient upright&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "fig0035"
        "etiqueta" => "Figure 7"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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        "figura" => array:1 [
          0 => array:4 [
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            "Tamanyo" => 150297
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Gufoni manoeuvre for ageotropic nystagmus&#47;Appiani&#44; for cupulolithiasis of the anterior arm of the horizontal canal &#40;right side&#41;&#46; We start with the patient sitting on the edge of the bed&#46; &#40;I&#41; We lie the patient down on the affected side &#40;right in this case&#41;&#59; &#40;II&#41; we turn the head 45&#176; towards the healthy side &#40;nose facing upwards&#41;&#59; &#40;III&#41; we sit the patient upright&#46;</p>"
        ]
      ]
      7 => array:7 [
        "identificador" => "fig0040"
        "etiqueta" => "Figure 8"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr8.jpeg"
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            "Tamanyo" => 139254
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        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Modification of the barbecue manoeuvre for canalithiasis of the anterior arm of horizontal canal &#40;right side&#41;&#46; Starting in the supine decubitus position the patient&#39;s head is turned towards the affected side &#40;right in this case&#41;&#44; to then start the barbecue manoeuvre from this position&#44; described in <a class="elsevierStyleCrossRef" href="#fig0030">Figure 6</a>&#46;</p>"
        ]
      ]
      8 => array:7 [
        "identificador" => "fig0045"
        "etiqueta" => "Figure 9"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr9.jpeg"
            "Alto" => 1746
            "Ancho" => 2333
            "Tamanyo" => 154854
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Diagnostic tests for canalithiasis of the anterior canal&#46;</p>"
        ]
      ]
      9 => array:7 [
        "identificador" => "fig0050"
        "etiqueta" => "Figure 10"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr10.jpeg"
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            "Tamanyo" => 134042
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Yacovino manoeuvre for canalithiasis of the anterior canal &#40;irrespective of the side&#41;&#58; starting with the patient seated on the bed &#40;a&#41;&#44; they are put into the cephalic hyperextension position &#40;b&#41;&#44; after 30<span class="elsevierStyleHsp" style=""></span>s &#40;or after the nystagmus has ceased&#41; the head is rapidly bent until the chin touches the chest &#40;c&#41;&#46; After 30<span class="elsevierStyleHsp" style=""></span>s &#40;or the nystagmus has ceased&#41; the patient is sat upright &#40;d&#41;&#46;</p>"
        ]
      ]
      10 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Side&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnostic test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus after sitting upright&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="middle">Right PC</td><td class="td" title="table-entry  " align="left" valign="top">Right Dix-Hallpike test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="201811180609248801"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top"><elsevierMultimedia ident="201811180609248802"></elsevierMultimedia></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Right lateral decubitus test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="201811180609248803"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="middle">Left PC</td><td class="td" title="table-entry  " align="left" valign="top">Left Dix-Hallpike test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="201811180609248804"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top"><elsevierMultimedia ident="201811180609248805"></elsevierMultimedia></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Left lateral decubitus test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="201811180609248806"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1897582.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Diagnosis of Canalithiasis of the Posterior Canal&#46;</p>"
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      ]
      11 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Affected side</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Position in the cephalic rotation test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Affected side</th></tr><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Left</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Right</th></tr><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="middle">Canalithiasis HC&#44; posterior arm</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="201811180609248807"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Latency &#60;10<span class="elsevierStyleHsp" style=""></span>s duration &#60;1<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="201811180609248808"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="201811180609248809"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488010"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="2018111806092488011"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488012"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488013"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1897580.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Diagnosis of Canalithiasis of the Posterior Arm of the Horizontal Canal&#46;</p>"
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      12 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
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            "identificador" => "at3"
            "detalle" => "Table "
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Affected side</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Position in the head roll test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Affected side</th></tr><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Left</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Right</th></tr><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="middle">Canalithiasis HC&#44; anterior arm</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488014"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="middle">Latency &#60;10<span class="elsevierStyleHsp" style=""></span>s duration &#60;1<span class="elsevierStyleHsp" style=""></span>min</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="2018111806092488015"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488016"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488017"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="2018111806092488018"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488019"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488020"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1897581.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Diagnosis of Canalithiasis of the Anterior Arm of the Horizontal Canal&#46;</p>"
        ]
      ]
      13 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
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            "identificador" => "at4"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Affected side</th><th class="td" title="table-head  " align="center" valign="top" scope="col">Position in the head roll test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Affected side</th></tr><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Left</th><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Right</th></tr><tr title="table-row"><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="3" align="left" valign="middle">Cupulolithiasis HC</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488021"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488022"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488023"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " rowspan="3" align="left" valign="middle">Latency&#58; no duration&#58; while the position is maintained</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="2018111806092488024"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488025"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488026"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="2018111806092488027"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488028"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488029"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab1897577.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Diagnosis of Cupulolithiasis of the Horizontal Canal&#46;</p>"
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      14 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
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            "identificador" => "at5"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Affected side&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " rowspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Bow and Lean manoeuvre</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Affected side&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Right&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Left&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Position&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Nystagmus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="middle">Posterior arm canalithiasis</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488030"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488031"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488032"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><elsevierMultimedia ident="2018111806092488033"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488034"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488035"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="middle">Anterior arm canalithiasis</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488036"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488037"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488038"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488041"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="middle">Cupulolithiasis</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488042"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488043"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Latency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Duration&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><elsevierMultimedia ident="2018111806092488050"></elsevierMultimedia>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Possible&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 21735735
Original language: English

DOI:10.1016/j.otoeng.2018.10.002

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