BPPV is a mechanical disorder caused by the displacement of otolith debris into the semicircular canals. The treatment involves different repositioning maneuvers to bring the debris back into the utricle. This study aims to show how dynamic simulation models based on fluid dynamics and MRI, can help to visualize and understand the movement of the debris within the canals during head movement in 3D as a function of time. The user can define the rotation angle and plane at each step of the maneuver and then the model visualizes the canal and the otoconial movement in 3D. The simulation developed also allows alteration of various parameters like the rotational head acceleration, the duration of each step of the maneuver, the initial position of the otoconial debris in the canal, the size and the number of the particles and fluid dynamics of endolymph. The clod movement is visualized in such a way that it allows a better understanding of the impact and efficacy of various liberation maneuvers and why certain maneuvers might fail when not applied properly in the clinic. The model allows simulation of multi-canal BPPV. In this paper we demonstrate the power of the model applied on the maneuvers of Semont and Yacovino when executed in different ways. The model aims to provide a visual explanation for the need of specific maneuvers for each type of BPPV. The simulator presented here can be used to test the efficacy of existing maneuvers and help in the development of new maneuvers to treat different BPPV variants.

Background and Objectives Current understanding based on older studies is that pc-BPPV is far more common than hc-BPPV. Such studies are limited by small sample sizes, and often the supine roll test for hc-BPPV is not performed. To better estimate the prevalence of hc-BPPV, we studied a large cross-section of patients with VOG-diagnosed BPPV. Methods Using a cross-sectional study of patients with BPPV, we investigated patients referred to NeuroEquilibrium specialty clinics throughout India between January 1, 2021, and December 31, 2021. All patients were evaluated with video oculography (VOG) during positional tests, and all diagnoses were confirmed by a neurotologist and neurologist. Results Of 3,975 patients with VOG-confirmed and specialist-diagnosed BPPV (median age, 51 years; 56.6% women), pc-BPPV accounted for 1,901 (47.8%), hc-BPPV was seen in 1,842 (46.3%), and anterior canal BPPV was found in 28 (0.7%) patients. Discussion This study found that hc-BPPV is far more common than previously reported. It is important to perform the supine roll test in addition to the Dix-Hallpike in all patients suspected with BPPV. Better training to diagnose patients with BPPV and to accurately recognize the nystagmus pattern of hc-BPPV should be a priority.

BACKGROUND: The aim of this study was to show the variability in head angulation during the canalolith repositioning maneuvers to treat benign paroxysmal positional vertigo and to describe a head-mounted benign paroxysmal positional vertigo guidance system to measure the head orientation. METHODS: A guidance system for benign paroxysmal positional vertigo was developed by NeuroEquilibrium Diagnostic Systems to measure head orientation and provide visual feedback and instructions to examiners during various maneuvers for benign paroxysmal positional vertigo. Twenty-five experienced examiners and 25 healthy volunteers (aged 21-35 years) were recruited. Each examiner applied the Epley maneuver twice in 1 volunteer: without and with the use visual feedback from a guidance system. Head orientation in both procedures was measured and compared. RESULTS: The trained examiners demonstrated a large variability in head orientation during the Epley maneuver, which was reduced by using the benign paroxysmal positional vertigo guidance system. There was a variability of 39-65° in head orientation measured without the guidance system. The use of the guidance system reduced the variation range to a sixfold decrease in variability. CONCLUSION: There is a large variability in head orientation when performing repositioning maneuvers, which could compromise the efficacy of benign paroxysmal positional vertigo treatment. Treatment for benign paroxysmal positional vertigo can be optimized by reducing this variability with a benign paroxysmal positional vertigo guidance system. It might also be a useful tool for teaching. Cite this article as: Bhandari R, Bhandari A, Kingma H, van de Berg R. Large variability of head angulation during the epley maneuver: Use of a head-mounted guidance system with visual feedback to improve outcomes. J Int Adv Otol. 2023;19(3):234-241.

BACKGROUND: Vertigo and dizziness in children can be multi-factorial. Vestibular function tests allow an improved differential diagnosis and treatment. Delay in diagnosis of the diverse etiologies causing dizziness can adversely affect the health of children and is a matter of concern for their families. This study analyzes the delay in diagnosis and the importance of establishing a diagnosis with detailed history and neuro-otological evaluation. METHODS: A total of 241 children presenting with vertigo to a tertiary otoneurology clinic between January 2019 and April 2022 were analyzed for the duration between the onset of symptoms and diagnosis, presenting complaints, and characteristic findings. RESULTS: Two hundred and forty-one patients with a mean age of 12.5 ± 3.02 years (range, 5-16 years) were evaluated. About 39.4% of patients were diagnosed after over a year (with some over 5 years) of suffering from vertigo and only 18.7% of patients were diagnosed correctly within 1 month of symptom onset. The presenting features were variable with 174 (72.2%) complaining of spinning, unsteadiness, and falls seen in 36+10+37 (34.4%). Vestibular migraine was the most common diagnosis (63.39%), followed by benign paroxysmal positional vertigo (24.48%), of which the posterior canal was most affected (50.85%) followed by horizontal (40.68%) and anterior canal (8.47%). Other etiologies noted were central (14.10%) and peripheral vestibulopathy (17.42%) and variable other causes (6.19%). CONCLUSION: Many pediatric vertigo and dizziness patients do not reach the correct diagnosis for long durations and are treated as “unspecified dizziness.” A detailed examination with a multidisciplinary approach including vestibular evaluation is advocated to give definitive treatment to these children. Cite this article as: Bhandari A, Bhandari R, Kumbhat P. Diagnostic delay in pediatric vestibular disorders. J Int Adv Otol. 2023;19(4):318-322.

Key Clinical Message: Repositioning maneuvers for benign paroxysmal positional vertigo (BPPV) designed to induce otoconial movement in one canal can trigger and sometimes unwittingly treat BPPV in other canals. Patients with BPPV are best managed by precisely diagnosing the canal variant and using correctly performed, standardized testing and treatment maneuvers.

Objective: To investigate the inter-method agreement between in-person consultations and video recordings when diagnosing BPPV. Methods: Two experienced vestibular clinicians (clinician A and B) evaluated patients for the presence and type of BPPV, using the TRV chair (Interacoustics, Middlefart, DK), at a tertiary referral center. During these in-person consultations, diagnostic maneuvers and eye movements were recorded, and a diagnosis was made. Both clinicians independently evaluated their cases again, during two video review sessions (Video Review 1 and Video Review 2). These sessions were conducted one month apart. Both clinicians were blinded to patient information and medical history during the analysis and did not have access to sound recordings. They were asked to provide a new diagnosis, based on the videos alone. Inter-method and intra-observer agreement for BPPV diagnoses between in-person consultations and video reviews were assessed using the percentage of agreement and Cohen’s kappa. An independent analysis of all patients’ eye movements was conducted to identify patterns that might have influenced agreement between in-person consultation diagnoses and the two video reviews by clinicians. Results: During the in-person consultations, each clinician evaluated 100 patients. Clinician A diagnosed BPPV in 40% of the cases, while clinician B diagnosed it in 19% of the cases. Considering the inter-method agreement, clinician A agreed on 81% (95% CI (73, 89)) and 77% (95% CI (69, 85)) of the cases with associated kappa coefficients of 0.67 (95% CI (0.55, 0.79)) and 0.63 (95% CI (0.51, 0.75)) between in-person consultations and Video Reviews 1 and 2, respectively. For clinician B, the percentages of agreement were, respectively, 86% (95% CI (79, 93)) and 84% (95% CI (77, 91)), with corresponding kappa coefficients of 0.55 (95% CI (0.36, 0.74)) and 0.51 (95% CI (0.32, 0.70)). As for the intra-observer agreement, clinician A achieved an intra-observer agreement of 84% (95% CI (77, 91)) with kappa = 0.74 (95% CI (0.63, 0.85)), while clinician B achieved a slightly higher intra-observer agreement of 90% (95% CI (84, 96)) with kappa = 0.67 (95% CI (0.51, 0.83)). Descriptive analysis of the eye movement revealed that both clinicians showed high diagnostic consistency for “no BPPV” in cases without provoked nystagmus (78/86, 91%) even when spontaneous nystagmus was present, and for posterior canal BPPV (37/78, 47%) when characteristic nystagmus was observed. However, disagreement was noted for horizontal canal BPPV (15 cases) and in scenarios with subjective BPPV (2 cases) or purely vertical nystagmus (11/31 cases, 35%). Conclusions: This study showed the feasibility of using video recordings when diagnosing BPPV. It demonstrates that BPPV might be reliably diagnosed in a telemedicine setting. However, careful consideration must be given to certain factors during the protocol’s design to improve the diagnostic process.