KISEP Otology Korean J Otolaryngol 1999;42: 외측반규관기원의양성발작성두위안진 연세대학교의과대학이비인후과학교실 정운교 이원상 김문석 이주환 이세영 Direction Changing Positional Nystagmus from

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1 KISEP Otology Korean J Otolaryngol 1999;42: 외측반규관기원의양성발작성두위안진 연세대학교의과대학이비인후과학교실 정운교 이원상 김문석 이주환 이세영 Direction Changing Positional Nystagmus from Canalolithiasis and Cupulolithiasis of Lateral Semicircular Canal Woon Kyo Chung, MD, Won-Sang Lee, MD, Moon Suk Kim, MD, Joo-Hwan Lee, MD and Sei Young Lee, MD Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, Korea ABSTRACT Background and Objectives:Clinical features of positional nystagmus may be different according to the etiology. Thus, efforts have been made to find out etiologies of various positional nystagmus. Until recently, positional vertigo was thought to arise from lesions of central nervous system. However, more recent investigations suggest that the peripheral lesion may be the main cause. Moreover, there have been some reports suggesting that directional changing positional nystagmus occurs due to canalolithiasis and cupulolithiasis of the lateral semicircular canal. The objectives of the study were to investigate the etiologies and clinical aspects of DCPN (direction changing positional nystagmus) from canalolithiasis and cupulolithiasis of the lateral semicircular canal, and to assess the effectiveness of the treatment. Materials and Methods:Among 15 patients with DCPN, 9 patients showed nystagmus compatible with canalolithiasis of lateral semicircular canal and 6 patients with cupulolithiasis of lateral semicircular canal. Patients with cupulolithiasis and canalithiasis of the lateral semicircular canal did not respond to physical therapy for posterior semicircular canal. However, they were completely recovered by reposition maneuver for the lateral semicircular canal with or without using vibrator although 3 of them had recurred symptom. Four patients had BPPV of the posterior semicircular canal prior to the development of DCPN and 3 patients underwent the treatment of previous Meniere's disease. Conclusion:The patients with DCPN were due to canalithiasis and cupulolithiasis of the lateral semicircular canal, and physical therapy for lateral semicircular canal was rewarding. (Korean J Otolaryngol 1999;42:576-81) KEY WORDS:Direction changing positional nystagmus Benign paroxysmal positional vertigo Cupulo- and canalolithiasis of lateral semicircular canal. 576

2 Table 1. Characteristics of DCPN according to type of lesion Canalolithiasis Cupulolithiasis Vertigo duration Short Short Latency Less than 30 seconds more than 30 seconds Geotropic transient Ageotropic persistent Nystagmus pure horizontal pure horizontal Baloh RW, Halmagyi GM. Disorder of the vestibular system. New York Oxford A B Fig. 1. Geotropic transient nystagmus of the patients with canalolithiasis in the right lateral semicircular canal. ALeft head rotation induces transient left beating nystagmus Duration of nystagmus was 15 seconds and Vmax was 17 sec. hdlhead left rotation, hdr head right rotation. BRight head rotation induces transient right beating nystagmus Duration of of nystagmus is 30 seconds and Vmax is 40sec. hdl head left rotation, hdrhead right rotation. 577

3 Fig. 2. Ageotropic persistent nystagmus in cupular type Head left rotation position induces right beating ageotropic persistent nystagmus. hdlhead left rotation, hdrhead right rotation. 578 Korean J Otolaryngol 1999;42:576-81

4 Table 2. Number, age distribution and vertigo duration of canalolithiasis and cupulolithiasis of the lateral semicircular canal Lateral canalolithiasis Lateral cupulolithiasis Number 9 6 Age Duration of vertigo 1 week week 1 month month 2 1 Table 3. Etiologies of canalolithiasis and cupulolithiasis of the lateral semicircular canal Canalolithiasis Etiology 3 Cupulolithiasis Meniere's diasease 2 1 Head trauma 1 1 Posterior BPPV* 1 Lateral cupulolithiasis 2 Unknown 9 4 Total 9 6 BPPV*benign paroxysmal positional vertigo Fig. 3. One positiondirection changing positional nystagmus in right canalolithiasis type Head right rotation position induced right beating nystagmus initially after 40 seconds it turns into left beating nystagm-us. hdl head left rotation, hdr head right rotation. 579

5 Fig. 4. Canalolithiasis of right lateral semicircular canal. Fig. 5. Cupulolithiasis of right lateral semicircular canal. 580 Korean J Otolaryngol 1999;42:576-81

6 REFERENCES 1) Watson P, Barber HO, Deck J, Terbrugge K. Positional vertigo and nystagmus of central origin. Le Journal Canadien Des Sciences Neurologiques ) Citron L, Hallpike CS. A case of positional nystagmus of the socalled be-nign paroxysmal type and the effects of treatment by intracranial division of the h nerve. J Laryngol ) McClure JA. Horizontal canal BPV. J Otolaryngol ) Baloh RW, Halmagyi GM. Disorders of the vestibular system. New York Oxford University Press1996. p ) Sakata E, Kyoko O, Hiromichi S, Shigeru S. Positional nystagmus of benign paroxysmal type BPPN due to cerebellar vermis lesions. Pseudo-BPPN. Auris Naris Larynx ) Barany R. Diagnose von Kraubeitsercheinungen im Berciche des Otolithenappates. Acta Otolaryngol Stockh ) Aschan G. The pathogenesis of positional nystagmus. Acta Otolaryngol 1961;Supplement ) Harrison MS. Notes on the clinical features and pathology of postconcussional vertigo, with especial reference to positional nystagmus. Brain ) Riesco MJS. Es el vertigo aural de origin exclusivement periffe ies. Rev Oto Rhinolaryngol ) Schuknecht H. Cupulolithiasis. Arch Otolaryngol Head Neck Surg ) Hall SF, Ruby RRF, McClure JA. The mechanisms of benign paroxysmal ve-rtigo. J Otolaryngol ) Brandt Th, Steddin S. Reply to the letter by Gordon.Benign paroxysmal positional vertigo BPPV or bubble provoked positional vertigo?j Neurol Sci ) Baloh RW, Jacobson K, Honrubia V. Horizontal semicircular canal variant of benign positional vertigo. Neurology ) Lempert T. Horizontal benign positional vertigo. Neurology ) Barber HO, Stockwell CW. Manual of Electronystagmography. 2nd ed. Mosby Company1980. p

KISEP Otology Korean J Otolaryngol 1999;42: 수평반고리관양성발작성두위현기증 김영기 윤용주 김인 Benign Paroxysmal Positional Vertigo of the Horizontal Semicircular Cana

KISEP Otology Korean J Otolaryngol 1999;42:836-42 수평반고리관양성발작성두위현기증 김영기 윤용주 김인 Benign Paroxysmal Positional Vertigo of the Horizontal Semicircular Canal Young Ki Kim, MD, Yong Joo Yoon, MD and In Kim MD