J Clin Neurol.  2019 Apr;15(2):143-148. 10.3988/jcn.2019.15.2.143.

Incidence and Clinical Significance of Positional Downbeat Nystagmus in Posterior Canal Benign Paroxysmal Positional Vertigo

• Oh EH
• Lee JH
• Kim HJ
• Choi SY
• Choi KD
• Choi JH

• KMID: 2467726
• DOI: http://doi.org/10.3988/jcn.2019.15.2.143

Abstract

BACKGROUND AND PURPOSE
The aim of this study was to determine the incidence and clinical significance of positional downbeat nystagmus (pDBN) after treatment of posterior canal (PC) benign paroxysmal positional vertigo (BPPV).
METHODS
We recruited 77 patients with a diagnosis of PC BPPV, and assessed the presence of pDBN during follow-up positional tests after performing the Epley maneuver.
RESULTS
An immediate response to the Epley maneuver was exhibited by 57 of the 77 patients, with resolution of their positional torsional upbeat nystagmus (pT-UBN). Twenty-two (39%) of them exhibited pDBN during follow-up tests performed 1 hour later. The latency and duration of pDBN were 3.2±2.0 and 12.0±10.0 s (mean±SD), respectively. The maximum slowphase velocity of pDBN was 5.1±2.5 degrees, and ranged from 2.0 to 12.2 degrees. A torsional component was also observed in six patients. The patients with pDBN were much more likely to develop a typical form of PC BPPV again at a 1-week follow-up (5/22, 23%) compared to those without pDBN (1/31, 3%; p=0.036). pDBN disappeared in all patients within 6 months.
CONCLUSIONS
Our study found transient pDBN in 40% of patients with PC BPPV after the immediate resolution of positional vertigo and pT-UBN. pDBN may be attributed to residual debris in the distal portion of the PC, which can move toward the ampulla producing an ampullopetal flow of endolymph during positioning.

Keyword

positional downbeat nystagmus; posterior canal benign paroxysmal positional vertigo; Epley maneuver

MeSH Terms

Benign Paroxysmal Positional Vertigo*
Diagnosis
Endolymph
Follow-Up Studies
Humans
Incidence*
Vertigo

Figure

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  Fig. 1 Treatment outcome, incidence of pDBN, and 1-week follow-up results in patients with PC BPPV. The responders were those patients with resolution of pT-UBN in follow-up tests performed 1 hour after the Epley maneuver. BPPV: benign paroxysmal positional vertigo, PC: posterior canal, pDBN: positional downbeat nystagmus, pT-UBN: positional vertigo and torsional upbeat nystagmus.

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  Fig. 2 Recording of positional nystagmus in a patient with right-side posterior canal benign paroxysmal positional vertigo. A: Initially, the right-side DH maneuver induced upbeat and CW torsional nystagmus. B: One hour after receiving the Epley maneuver, downbeat nystagmus with a small counterclockwise torsional component was observed during the right-side DH maneuver. Upward deflection indicates upward and CW eye motion from the patient's perspective. CW: clockwise, DH: Dix-Hallpike, LT: torsional position of the left eye, LV: vertical position of the left eye.

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  Fig. 3 Positional downbeat nystagmus due to canalolithiasis in the nonampullary arm of the PC. A: During the Epley maneuver, some otoconial debris can remain in the nonampullary arm of the PC near the common crus (red arrowhead). B: When a patient lies down to assume the head-hanging position, the residual debris in the PC (red arrowhead) moves toward the ampulla, producing an ampullopetal flow of endolymph and downbeat nystagmus. PC: posterior canal.

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