Background and Clinical Significance: The concurrent presence of a thyrotropin-secreting hypophyseal adenoma (TSHoma) with a thyroid malignancy, such as papillary thyroid carcinoma (PTC), is exceptionally rare and significantly complicates clinical diagnosis and management. This rare combination raises difficult decisions regarding the treatment sequence and carries the risk of exacerbating either or both conditions. Case report: We present the case of a 59-year-old female patient exhibiting persistent hyperthyroid symptoms with unusually normal TSH levels despite elevated thyroid hormone concentrations. Initial diagnostic imaging revealed a hypophyseal macroadenoma and a diffuse nodular goiter. After the macroadenoma diagnosis, the patient initially refused surgical intervention, and subsequent dopamine agonist therapy proved ineffective. Eight years later, during a routine follow-up, a thyroid ultrasound revealed a diffuse nodular goiter classified as EU-TIRADS 5, and papillary thyroid carcinoma was confirmed through fine needle aspiration biopsy. A total thyroidectomy and subsequent radioactive iodine therapy were performed. However, persistently elevated postoperative TSH levels remained despite high-dose levothyroxine therapy. Due to the increased risk of malignancy recurrence associated with elevated TSH levels, the patient consented to macroadenoma surgery. A successful transsphenoidal macroadenomectomy stabilized the patient’s condition, allowing for the normalization of TSH levels. Conclusions: This case underscores the importance of accurate differential diagnosis and highlights the challenges in managing TSH levels in patients with coexisting thyroid malignancies. With there being no clear guidelines for managing the combination of these conditions, decisions regarding treatment priority should consider the patient’s preferences, the risk of malignancy recurrence or progression, neurological symptoms, and the aggressiveness of the thyroid tumor.

Background and Clinical Significance: Benign paroxysmal positional vertigo (BPPV) most commonly involves the posterior semicircular canal (PSC), whereas anterior semicircular canal BPPV (ASC-BPPV) is rare, accounting for only 1–3% of cases. Most ASC-BPPV cases respond well to particle repositioning maneuvers (PRMs), with refractory presentations being exceptional and diagnostically challenging, particularly when differential diagnoses such as apogeotropic posterior semicircular canal BPPV (PSC-BPPV) or central causes must be excluded. Case Presentation: A 43-year-old woman presented with vertigo triggered by head extension and rolling in bed. Initial neurological and otoneurological examinations were unremarkable. During the left Dix–Hallpike maneuver, a vertical down-beating nystagmus with subtle leftward torsion appeared after a 5 s latency and lasted 15 s. The supine head-hanging maneuver provoked a stronger and longer 30 s response, while the right Dix–Hallpike was negative. Despite repeated PRMs, including Yacovino (Deep Head-hanging), reverse Epley, Epley, and modified Semont maneuvers, the patient remained symptomatic over three years. Intermittently, conversion to PSC-BPPV was suspected, and temporary resolution was achieved after left-sided Epley and Semont maneuvers, but recurrence followed. Treatment with a mechanical rotational chair (TRV) initially resolved symptoms, but vertigo recurred several months later following two syncopal episodes with minor trauma. Extensive neurological evaluation, including MRI, CT, EEG, and vascular ultrasound, excluded central causes. Conclusions: This case illustrates the diagnostic and therapeutic difficulties posed by refractory ASC-BPPV, particularly in differentiating it from apogeotropic PSC-BPPV and central etiologies. It underscores the importance of latency, torsional characteristics, and supine head-hanging testing in diagnosis and demonstrates the potential role of mechanical rotational chairs in management. Personalized approaches incorporating anatomical imaging and maneuver adaptation are essential in such complex cases.