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1 Cupulolithiasis

2 Cupulolithiasis

4 ,.,,..,,

5 (post - treatm ent instruction ) 4. cupulolithiasis Cupulolith Repositioning M aneuver (CuRM ) canalolithiasis

6 Fig. 1. Schem atic dr aw ing and T empor al bone CT of right side later al semicircular canal. 8 Fig. 2. Ageotropic per sistent direction changing horizontal position al ny stagmus of the patient with cupulolithiasis in the right side later al semicircular canal. 11 Fig. 3. Schem atic dr aw ing illustr ating how otoliths att ached to the cupula of the right later al semicircular can al can produce ageotropic direction changing horizont al position al ny stagmus and the pathophysiologic m echanism of the ex cit atory and inhibitory ny stagmus in right side later al semicircular can al cupulolithiasis. 17 Fig. 4. Schem atic dr aw ing of Cupulolith Repositioning M aneuv er (CuRM ) in case of the right side later al semicircular canal cupulolithiasis. 20 Fig. 5. Incorrect Cupulolith Repositioning M aneuver 21 Fig. 6. Schem atic dr aw ing illustr ating how free floating otoliths in the right later al semicircular can al can produce geotropic direction - changing horizontal position al nystagmus and the pathophy siologic m echanism of the ex cit atory and inhibitory ny stagmus in right side later al semicircular can al canalolithiasis 23 Fig. 7. Modified Barbecue rotation in the treatment of the right side later al semicircular canal can alolithiasis 24

7 T able 1. Angle betw een the anterior semicircular canal and sagittal plane 7 T able 2. Clinical features of 23 cases of later al semicircular canal cupulolithiasis 12 T able 3. T reatment results of cupulolith repositioning m aneuv er (CuRM ) 13

8 Cupulo lithia s is cupulolithiasis Curthoy s, (Cupulolith Repositioning Maneuver ; CuRM ) cupulolithiasis 23 CuRM CuRM, , 3. cupulolithiasis,. CuRM cupulolithiasis. : cupulolithiasis cupulolith repositioning maneuver (CuRM ) - 1 -

9 Cupulo lithia s is < > I. (Benign Paroxysmal Positional Vertigo; BPPV ) 1897 Adler, 1921 Barany 1, 1952 Dix Hallpike 2 (Dix - Hallpike maneuver ). Dix Hallpike (Dix - Hallpike position ) (geotropic), (torsional) ( ) (rever sal) (fatigability ), canalolithiasis Schuknecht 3 cupula (basophilic deposit ) 1969 cupula cupula cupulolithiasis. cupulolithiasis Dix Hallpike, - 2 -

10 1979 Hall 4 (utricular macule) (otoconia) (canaliths) canalolithiasis, 1988 Semont Epley maneuver 6 (reposition maneuver ). canal (common crus ) Herdman 7 60, 90%, canalolithiasis McClure 11 (geotropic) canalolithiasis 1996 Lempert 12 Barbecue rotation 1997 Vannucchi 13 forced prolonged position Ciniglio canalolithiasis 1998 Nuti 15 ) Baloh 16 canalolithiasis (fatigability ) cupulolithiasis 3 cupula (utricle side) cupula (per sistent ), (ageotropic). Baloh

11 cupulolithiasis (Supine Head- T urning T est ), 1996 Nuti 17. cupulolithiasis. cupulolithiasis

12 cupulolithiasis ,, 6. (Nicolet Nystar Plus ver sion 4.33),,,,, Frenzel.. 3., - 5 -

13 .. cupulolithiasis Curthoys 18 (membranous) Baloh 19 (T emporal bone CT ) canalolithiasis cupulolithiasis,. 2 0 (common crus) (sagittal plane) 8. 37, 41, 45 Baloh (T able 1) Curthoys 18 (sagittal plane) 30 cupula Curthoys 18 (Fig. 1)

14 T able 1. A n g le b et w e en th e an terior s e m ic ircular c an al an d s ag itt al plan e. T he angle betw een 100 anterior semicircular canals and sagittal plane from CT s of 50 patient s ' tempor al bone are m easur ed bilater ally. S e ria l No. S e x/ Age Rig ht Le ft S e ria l No. S e x/ Ag e Rig ht Le ft 1 M/ M/ F/ F/ M/ M/ M/ F/ F/ F/ M/ M/ M/ M/ F/ F/ F/ F/ M/ F/ M/ M/ F/ F/ M/ M/ F/ F/ M/ M/ M/ F/ M/ F/ M/ M/ M/ M/ F/ F/ F/ F/ F/ F/ F/ M/ F/ F/ F/ M/ Ave ra ge : Rig ht = 30.8 Le ft = 29.8 Tota l =

15 A. B. F ig. 1. S ch e m atic draw in g (A ) an d tem poral b on e CT (B ) of rig ht s ide lat eral s em icircular c an al

16 . Cupulolith Repositioning Maneuver (CuRM ). 60 Hz suprameatal triangle

17 , , , canalolithiasis 1, canalolithiasis 5, 12 (T able 2).,,.. (Fig. 2), Frenzel Frenzel, 5 (peak slow phase velocity) 10 /. 17, canalolithiasis cupulolithiasis

18 , 1 canalolithiasis, 1 canalolithiasis (T able 2). F ig. 2. A g e otropic pers is t ent dire ction c h an g in g h oriz ontal po s ition al n y s tag m u s of th e patien t w ith c upulolithia s is in th e rig ht s ide lateral s em icirc ular c an al. Left head rotation in supine position induces strong right beating per sistent ex citat ory ny stagmu s (Vm ax w as 126 degr ee/ sec). Right head r otation induces w eak left beating per sistent inhibitory ny stagmu s (Vmax w as 53 degree/ sec). hdl : head left r otation, hdr : head right rotation.,,,, , 17 CuRM, 4 CuRM, 1 CuRM (T able 3)

19 T able 2. Clinic al f e ature s of 23 c a s e s of lateral s e m ic ircular c an al c upulolithias is Cas e No. S ex/ Age Duratio n (days ) S uppos e d Etio logy o r othe rs Le s io n s ide CP (%) P/MS V in HRP (de g/s e c) P/ MSV in HLP (de g/s e c) 1 M/58 15 R L 4 53/36 126/67 2 F/28 7 Meniere's disease(r) R R42 17/11 34/20 3 F/84 3 Head trauma R F/79 14 R 5/4 28/10 5 M/60 1 Acute vestibuloneuritis R R20 28/24 46/31 6 F/56 3 Head trauma, ARMPC(R) R R M/49 1 R F/69 7 ARMPC(R) R R F/47 1 Head trauma R M/59 2 ARMLC(L) L R M/62 3 R F/28 1 L L13 46/30 22/16 13 M/66 90 ARMPC(L) L R M/70 2 L L19 51/34 26/20 15 M/74 4 R R30 23/15 66/40 16 M/72 3 R R19 15/11 60/31 17 F/65 1 L R F/56 1 R 32/20 39/25 19 F/68 5 R R20 32/21 42/26 20 F/72 1 With PC(R) R R14 9/8 7/6 21 M/74 2 PCARM(R) R R26 16/12 11/8 22 M/45 3 ARMLC(R) R R 2 26/19 18/13 23 F/62 14 Meniere's disease(r)? R 5 33/20 27/18 P/MSV : Peak / Mean Slow- phase velocity PC : Posterior canal Canalolithiasis HRP : Head Right Position CP : Canal Paresis HLP : Head Left Position ARMPC : After Reposition Maneuver for Posterior canal Canalolithiasis ARMLC : After Reposition Maneuver for Lateral canal Canalolithiasis PCARM : Posterior canal Canalolithiasis After Repositioning Maneuver

20 T able 3. T re atm ent re s ult s of cupulolith repo s itionin g m an euv e r (CuRM ) Num ber of attem pts Number of patient (% ) Spontaneou sly resolv ed 1 (4.3% ) Resolv ed after fir st CuRM 17 (73.9% ) Resolv ed after s econ d CuRM 4 (17.4% ) Resolv ed after third CuRM 1 (4.3% ) T otal 23 (100% )

21 McClure 1 1 canalolithiasis cupulolithiasis 16,17,. 1.,, cupulolithiasis canalolithiasis., canalolithiasis. canalolithiasis positioning nystagmus cupulolithiasis positional ny stagmus. Dix - Hallpike. Dix - Hallpike cupula

22 2. cupulolithiasis canalolithiasis,., cupula cupula., cupulolithiasis Nuti 17. cupula (ampullopetal) (excitatory nystagmus ) cupula (ampullofugal) (inhibitory nystagmus)., canalolithiasis cupulolithiasis., 5 3 Baloh 16,,

23 3. (pos t- tre atme nt ins tructio n) cupulolithiasis canalolithiasis cupula c upulo lithias is cupulolithiasis cupula cupula (deviation)., cupulolithiasis, Fig

24 F ig. 3. S ch e m atic draw in g illu s tratin g h ow ot olith s att ac h e d to th e c upula of th e rig ht lat eral s em icirc ular c an al c an produ c e ag e otropic dire ction - c h an g in g h oriz ontal po s ition al ny s tag m u s an d th e path ophy s iolog ic m e ch anis m of th e e x c itatory an d in hibit ory n y s tag m u s in rig ht s ide lat eral s em icirc ular c an al c upulolithias is. T he shape of the lateral semicir cular canal is taken fr om photograph s of a semicircular membr anou s canal dissected fr om a fetu s by Curthoy s and Oman. 18 ) T he position of the utricle and ampulla relative to the head was derived from CT s of human temporal bones w ith cut s thr ough the lat eral semicircular canals. Note that the cupula is par allel w ith the sagittal plane

25 cupula ( ) ( ) cupula (ampullopetal) ( ) (excitatory ny stagmus) ( ) cupula (ampullofugal) (inhibitory nystagmus). canalolithiasis, Dix - Hallpike position test. (lesion side). 5. Cupulo lith Re pos itio ning Mane uve r (CuRM) Frenzel cupulolithiasis cupula cupulolithiasis cupula. cupula (CuRM ) Fig. 4. (starting position ) (1st position) 60 Hz

26 . cupula Nuti 17. Fig cupula canalolithiasis., canalolithiasis (rever sal of ny stagmus). cupula cupula. 3. cupula. cupula cupula. 3 3,

27 F ig. 4. S c h em atic draw in g of Cupulolith R epo s itionin g M an e uv er (CuRM ) in c as e of th e rig ht s ide late ral s em icircular c an al c upulolithias is

28 F ig. 5. In c orre c t Cupulolith R epo s itionin g M an euv er In a lateral decubitu s position w ith head rotat ed 90 degr ees to the diseased side, vibr ating the mastoid ar ea cau ses the otolith s w hich ar e attached to the canal side of cupula to fall off and move to the ampulla. If w e proceed w ith head rotation t o the opposite side from this position, the otolith s will be remained at the ampulla

29 6. ca na lo lithias is canalolithiasis, Fig Vannucchi 13 forced prolonged position canalolithiasis Fig. 6., Fig (modified barbecue rotation ; 180 ) Lempert 12 Barbecue rotation cupula. canalolithiasis cupulolithiasis

30 F ig. 6. S ch e m atic draw in g illu s tratin g h ow fre e floatin g otolith s in th e rig ht lateral s em icirc ular c an al c an produ c e g e otropic dire ction - c h an g in g h oriz ontal po s ition al ny s tag m u s an d th e path ophy s iolog ic m e ch anis m of th e e x c itatory an d in hibit ory n y s tag m u s in rig ht s ide lateral s e m ic ircular c an al c an alolithias is. T he shape of the lateral semicir cular canal is taken fr om photograph s of a semicircular membr anou s canal dissected fr om a fetu s by Curthoy s and Oman. 18 ) T he position of the utricle and ampulla relative to the head was derived from CT s of human temporal bones w ith cut s thr ough the lat eral semicircular canals

31 F ig. 7. M odifie d B arb e cu e rot ation in th e tre atm ent of th e rig ht s ide late ral s em icirc ular c an al c an alolithia s is. After 3 minutes have past w ith patient in supine head center position, patient switches to the 1st position and continues on t o the 2nd position. T hey are m ade by r otating the head twice, 90 degrees each t o the health side w ith a interv al of 3 minutes betw een them. Finally, patient slowly changes to a sitting position. After the r otation m aneuver has been succes sfully conducted, advise neither to lie down nor to incline head to the diseased side until going to bed and maintain later al decubitu s position to the healthy side w hile sleeping as w ell

32 . cupulolithiasis, cupula (excitatory ny stagmus) (inhibitory nystagmus ).,.,,,. cupula (CuRM ), cupulolithiasis

33 1. Barany R. Diagnose v on Kr ankheit sercheimtngen im Ber eiche des Otolighenappar ates. Act a Otolaryngol 1920;2: Dix R, Hallpike CS. T he pathology, sympt om atology, and diagnosis of certain common disorder s of the v estibular sy stem. Pr oc R Sot Med 1952;54: Schuknecht H. Cupulolithiasis. Arch Otolaryngol Head Neck Sur g 1969; Hall SF, Ruby RRF, McClure JA. T he mechanism of benign paroxy sm al v ertigo. J Otolaryngol 1979;8: Semont A, Frey ss G, Vitte E. Curing the BPPV with a liberat ory maneuv er. Adv Otorhinolaryngol 1988;42: Epley JM. T he canalith repositioning procedur e: for treatment of benign paroxy sm al positional vertigo. Otolaryngol Head Neck Sur g 1992;107: Her dman SJ, T usa RJ, Zee DS, Proctor LR, Mattox DE. Single treatment approaches t o benign paroxy smal positional vertigo. Arch Otolaryngol Head Neck Sur g 1993;119: Brandt T h, Steddin S, Daroff RB. T her apy for benign par oxy sm al positioning vertigo, r evisited. Neurology 1994;44:

34 9. Li JC. Mastoid oscillation : a critical factor for success in canalith repositioning procedure. Otolaryngol Head Neck Sur g 1995;112: Lempert T, Wolsley C, Davis R, Gresty MA, Bron stein AM. T hr ee hundred sixty - degree rotation of the post erior semicir cular canal for treatment of benign positional v ertigo: A placebo- contr olled trial. Neur ology 1997;49: McClure JA. Horizontal canal BPV. J otolaryngol 1985;14: Lempert T, T iel- Wilck K. A positional maneuv er for treatment of horizontal- canal benign positional vertigo. Laryngoscope 1996;106: Vannucchi P, Giannoni B, Pagnini P. T r eatm ent of horizontal semicir cular canal benign par oxy sm al positional v ertigo. J Vest Res 1997;7: Ciniglio AG, Gagliardi M, Magliulo G. Phy sical tr eatment of horizontal canal benign positional vertigo. Eur Ar ch Otorhinolaryngol 1997;254: Nuti D, Agu s G, Barbieri M, Passali D. T he m anagem ent of horizont al- canal par oxy sm al positional v ertigo. A cta Ot olaryngol (Stockh ) 1998;118: Baloh RE, Yue Q, Jacobson KM, Honrubia V. Per sistent dir ection- changing positional ny stagmu s : another v ariant of benign positional ny st agmu s? Neur ology 1995;45:

35 17. Nuti D, Vannucchi P, Pagnini P. Benign paroxy sm al positional vertigo of the horizontal canal: a form of canalolithiasis with v ariable clinical featur es. J Vest Res 1996;6: Curthoy s IS, Oman CM. Dimen sions of the horizontal semicircular duct ampulla and utricle in the hum an. Acta Otolaryngol (Stockh) 1987;103: Baloh RW, Halmagyi GM. Disor der s of the v estibular sy stem. New York : Oxfor d Univ er sity Press;1996. p Kim YK, Yoon YJ, Kim I. Benign paroxy sm al positional vertigo of the horizont al semicircular canal. Kor ean J Otolaryngol 1999;42:

36 Abs tra ct Effe ctive ne s s of Cupulo lith Re pos itio ning Ma ne uve r in the tre atme nt of late ra l s e mic irc ula r ca na l c upulo lithias is S ung- Wo o Jo D ep artm ent of M edicine T he Graduate S chool, Y ons ei Univ ers ity (Directed by Professor W on - Sang Lee) T her e are still contr ov er sies in lesion side differ entiation and treatment of the later al canal cupulolithiasis. T he purpose of this study is aimed to the under standing, side differentiation, and tr eatm ent of this disease thr ough the analy sis of clinical features, electrony stagmogr aphic (ENG) r esult s, tr eatm ent maneuv er s, and their effectiveness. T w enty three patient s w ho show ed ageotropic dir ection- changing horizontal positional ny stagmu s w er e included in this study. Supine head turning test w as performed to induce positional ny stagmus. Clinical finding s and typical features of the ny stagmu s w ere recor ded. Neur ologic ex amination s, ENG test s, and MRI (6 cases ) w er e checked to ex clude the possibility of any centr al lesion s. Cupulolith Repositioning Maneuv er (CuRM ) w as applied and then they w er e in structed to keep the healthy side lateral decubitu s position w hile sleeping. T he ny stagmu s had a short latency, no fatigability, and per sistency in char acter. One patient w as resolved spontaneou sly, so w e could not decide the lesion side. Sev enteen out of 22 patient s show ed significant differ ence betw een the inten sity of both side ny st agmu s, and all of them show ed m or e strong ny stagmu s w hen the head w as rotat ed to the

37 unaffected side. In five patients who show ed no significant difference betw een the inten sity of both side ny st agmu s, tw o cases show ed same r esult s but thr ee cases show ed opposite result s. T ypical ny stagmus and spinning sen sation in supine head- turning test had completely subsided after phy sical therapy. In the cupulolithiasis of later al semicir cular canal, ageotropic ny stagmu s is more str ong when the pathological ear is at the uppermost position, and this ex citatory ny stagmu s beat s to the lesion side. But, if ther e is no significant differ ence betw een the intensity of both side ny stagmu s, as sociated canal par esis, other types of BPPV, past history of acute v estibuloneuritis, Menier e ' s disease et c might be helpful to localize the lesion side. CuRM and post - tr eatm ent later al decubitu s position kept during the night (while sleeping on the day of tr eatm ent ) are effective in treating the cupulolithiasis of later al semicircular canal. K e y W ord s : cupulolithiasis, later al semicircular canal, cupulolith r epositioning maneuv er (CuRM )

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

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