Ann Otol Rhinnl Uirynnot 114;200S

COMBINED HORIZONTAL AND POSTERIOR CANAL BENIGN

PAROXYSMAL POSITIONAL VERTIGO IN THREE PATIENTS
WITH HEAD TRAUMA
PIERRE BERTHOLON, MD
LARBI CHELIKH. MD
ANDREI P, TIMOSHENKO, MD
STEPHANE TRINGALI. MD
CHRISTIAN MARTIN, MD
SAINT-ETIENNE, FRANCE
We report 3 patients who complained of positional vertigo shortly after head trauma. Positional maneuvers performed in the
plane of the posterior canal (PC: Dix-Hallpike maneuver) and ihe horizontal canal (HC: patients were rolled to either side in a supine
position wiUi the head raised 30") revealed a complex positional nystagmus that could only be inierpreied as the result of combined
PC and HC benign paroxysmal positional vertigo (BPPV). Two patients had a right PC BPPV and an ageotropic HC BPPV. and I
patient had a bilateral PC BPPV and a left geotropic HC BPPV. All 3 patients were rapidly free of vertigo after the PC BPPV was
cured hy the Epiey maneuver and the geotropic HC BPPV was cured by the Vannucchi method. The ageotropic HC BPPV resolved
spontaneously. Neuroimaging (brain computed tomography and/or magnetic resonance imaging scans) findings were normal in all 3
patients. From a physiopathological viewpoint, it is easy to conceive thai head trauma could throw otoconia! debris into different
canals of each labyrinth and be responsible for these combined forms of BPPV. Consequently, in trauma patients with vertigo, il is
mandatory to perform the Dix-Hallpike maneuver, as well as supine lateral head turns, in order to diagnose PC BPPV, HC BPPV, or
the associalion of bolh. Early diagnosis and treatment of BPPV may help to reduce the postconcussion syndrome.
KEY WORDS benign paroxysmal positional vertigo, head trauma, positional nystagmus.
INTRODUCTION
Benign paroxysmal positional vertigo (BPPV) is
a common otologic disorder characterized by brief
episodes of vertigo induced by changes in head po-
sition. The posterior canal (PC) variant of BPPV is a
well-recognized condition in which a paroxysmal ro-
tatoi^-upbeat nystagmus is triggered by the Dix-Hall-
pike maneuver to one side.' In 1985. McClure^ de-
scribed the horizontal canal (HC) variant of BPPV
in 7 patients. Tbe nystagmus was horizontal, geotrop-
ic, and triggered by right and left positional maneu-
vers. These maneuvers included the Dix-Hallpike
maneuver and a more optimal maneuver that con-
sisted of rolling the head of a recumbent patient from
side to side. The positional nystagmus was paroxys-
mal. In 1995. Baloh et al' described a new form of
HC BPPV in 3 patients in whom the horizontal posi-
tional nystagmus was ageotropic when the head of
tbe patient was rolled from side to side. Tbis position-
al nystagmus was long-lasting.-'-'*
Although BPPV is usually idiopathic. there is clear
evidence that head trauma is the most common cause;
it accounts for 11% of cases of PC BPPV^ and 20%^^
to 23^r'' of cases of geotropic HC BPPV. Ageotropic
HC BPPV, which is less common than geotropic HC
has rarely been reported after head trau-
Interestingly, there is also clear evidence tbat
bilateral PC BPPV is more prevalent in posttraumatic
cases tban in idiopathic cases.'^ However, in the con-
text of head trauma, the association of PC BPPV and
geotropic HC BPPV has rarely been reported,"-'^
and to the best of our knowledge, there has been no
report of PC BPPV combined with ageotropic HC
BPPV. We are tberefore reporting tbe association of
PC BPPV. unilateral or bilateral, witb HC BPPV in
3 patients in whom the horizontal positional nystag-
mus was ageotropic in 2 cases and geotropic in 1
case.
PATIENTS AND METHODS
All 3 patienis underwent a complete otoneurologic
examination including systematic positional maneu-
vers in the plane of the PC (Dix-Hallpike maneu-
ver)' and the plane ofthe HC (HC maneuver). The
HC maneuver consists of rolling the head ofa recum-
bent patient from side to side- with the head lifted
30 from the table in order to bring the HC into a
plane of maximum influence (Figs 1 -3).^-^^ The posi-
tional nystagmus was detected by direct clinical ob-
servation with the patient's eyes in primary gaze fix-
ating on tbe examiner's face.'"' ^ Pure tone audiom-
etry was performed and neuroimaging (brain com-
puted tomography [CT] and/or magnetic resonance
imaging [MRI]) in order to rule out a cerebellar or
From the Department of Otorhinolaryngnlngy-Head and Neck Surgery. Bellevue Hospital. Saint-Etienne. France.
CORRESPONDENCE Pierre Bertholon. MD. Service ORL. Hopiial Bellevue, 42055 Saiiil-Etiennc codex 2. France.
105
106
Bertholon et al. Vertigo Following Head Trauma
D
Fig 1. (Case I) Positional nystagmus observed during
positional maneuvers. A) Clockwise rotatory-upbeat nys-
tagmus (curved arrows) followed by left horizontal nys-
tagmus (straight arrows) on right Dix-Hallpike maneuver.
B) Righl horizonlal nystagmus on left Dix-Hallpike ma-
neuver. C) Lell horizontal nystagmus on right horizontal
canal (HC) maneuver. D) Right horizontal nystagmus on
left HC maneuver.
brain stem lesion. Other investigations were avail-
able according to clinical needs.
We suspected BPPV when the patient described
short-lived episodes of acute vertigo provoked by
specific head positions (turning in bed. getting in and
out of bed. looking up, or bending over), and it was
confirmed by observing a characteristic nystagmus
during the positional maneuvers. The diagnosis of,
for example, a right PC BPPV requires the presence
of a paroxysmal clockwise rotatory-upbeat nystag-
mus triggered by a right Dix-Hallpike maneuver. The
rotatory component is clockwise from the patient's
point of view; ie, the upper pole of the eyes beats to
the patient's right shoulder. The diagnosis of a geo-
tropic HC BPPV requires a direction-changing hori-
zontal geotropic nystagmus triggered by the HC ma-
neuver; ie. the right HC maneuver induces a right
horizontal-beating nystagmus, and the left HC ma-
neuver induces a left horizontal-beating nystagmus.''
The horizontal positional nystagmus is paroxysmal
and more intense on the side corresponding to the
side of the affected ear^-^-''-'^-!-* The diagnosis of an
ageotropic HC BPPV requires a direction-changing
horizontal ageotropic nystagmus triggered by the HC
maneuver; ie, the right HC maneuver induces a left
horizontal-beating nystagmus, and the left HC maneu-
ver induces a right horizontal-beating nystagmus.-^
Fig 2. (Case 2) Positional nystagmus observed during
positional maneuvers. A) Clockwise rotatory-upbeal nys-
tagmus on right Dix-Hallpike maneuver. B) Righl hori-
zonlal nystagmus on left Dix-Hallpike maneuver. C) Left
horizontal nystagmus on right HC maneuver. D) Righl
horizontal nystagmu.s on left HC maneuver.
The horizontal positional nystagmus is long-lasting-^-'^
and is usually more intense on one side.-^-^'"' which
may even be the side ofthe nonaffected ear.^'"* How-
ever, it is often difficult to know which ear is affected,
inasmuch as there may be little or no asymmetry of
the nystagmus between the
Case I. A 19-year-old man with no significant med-
ical history was hospitalized after a fall on August 7,
2000, that caused a head trauma and a few hours'
loss of consciousness. A head CT scan showed an
isolated extralabyrinthine fracture of the right tem-
poral bone. The patient also presented a fracture of
the clavicle, which was repaired surgically. He was
referred on August 21 for positional vertigo that oc-
curred particularly when rolling onto his right or left
side in bed. The findings ofthe otoneurologic exam-
ination were normal, except for the positional maneu-
vers (Fig 1). The right Dix-Hallpike maneuver trig-
gered a paroxysmal clockwise rotatory-upbeat nys-
tagmus followed by a left horizontal nystagmus. Tbe
left Dix-Hallpike maneuver triggered a right horizon-
tal nystagmus. The right HC maneuver induced a left
horizontal nystagmus, and the left HC maneuver in-
duced a right horizontal nystagmus. The vertigo and
nystagmus were slightly more pronounced for the lefl
HC maneuver. This clinical presentation sugge.sted
a right PC BPPV associated with an ageotropic HC
BPPV. possibly involving the right HC. An Epiey ma-
neuver'^ was performed for the right PC BPPV. and
Bertholon et at. Vertigo Foltowing Head Trauma 107
Fig 3. (Case 3) Positional nystagmus observed during
positional maneuvers. A) Clockwise rotalory-upbeat nys-
tagmus on right Dix-Hallpike maneuver. B) Counter-
clockwise rotatory-upbeat nystagtnus on left Dix-Hall-
pike maneuver. C) Righl horizontal nystagmus on right
HC maneuver. D) Left horizontal nystagmus on left HC
maneuver.
the rotatory-upbeat nystagmus did not appear dur-
ing the right Dix-Hallpike maneuver when the pa-
tient was reassessed on August 25. At tbis time, the
HC maneuvers revealed the persistence ofthe ageo-
tropic horizontal nystagmus, but this had spontane-
ously disappeared when the patient was reexamined
on September 5. Although the patient had no defi-
nite hearing complaint, pure tone audiometry revealed
a slight right-sided high-frequency sensorineural hear-
ing loss. The patient was not examined again. He
was telephoned in June 2004 as part of this study
and reported no recurrence of positional vertigo.
To summarize, the patient had a right-sided PC
BPPV that was cured by the Epley maneuver. It was
associated with an ageotropic HC BPPV that may
have involved the right HC.
.f 2. A 51-year-old man with no significant med-
ical history was hospitalized after a fall on December
13,2001, that caused head trauma but no loss of con-
sciousness. One hour after falling, he complained of
spontaneous, as well as superimposed, positional ver-
tigo and vomited. A brain CT scan was normal. An
otoneurologic examination on December 17 revealed
a slight right-beating horizontorotatory nystagmus
when the patient looked straight, up, or to the right
side. This nystagmus was more pronounced under
Frenzel glasses and after head-shaking. The Rom-
berg and Fukuda tests showed a tendency to deviate
to the left side after eye closure. The right Dix-Hall-
pike maneuver triggered a violent clockwise rota-
tory-upbeat nystagmus, and the maneuver had to be
stopped. The left Dix-Hallpike maneuver induced a
right horizontal nystagmus. An HC maneuver on the
right triggered a left horizontal nystagmus, and one
on the left side triggered a right horizontal nystag-
mus (Fig 2). The findings of the neurologic exami-
nation were otherwise normal. Videonystagmography
showed spontaneous right-beating horizontorotatory
nystagmus associated with a left canal paresis on ca-
loric stimulation. Pure tone audiometry revealed a
mild bilateral symmetric bigh-frequency sensorineu-
ral hearing loss. The patient was reassessed on De-
cember 27. He no longer had spontaneous vertigo,
but still complained of positional vertigo when bend-
ing forward or tuming onto his right side in bed. He
had no nystagmus during fixation, under Frenzel
glasses, or after head-shaking. The HC maneuvers
and the left Dix-Hallpike maneuver were negative.
The right Dix-Hallpike maneuver showed a parox-
ysmal clockwise rotatory-upbeat nystagmus (Fig 2),
for which an Epley maneuver was performed. On
January 4, 2001, the patient had no vertigo, and an
otoneurologic examination, including all positional
maneuvers, revealed normal findings.
The patient was seen again in November 2003 dur-
ing a third period of recurrent episodes of positional
vertigo. Each of these three periods lasted for less
than 2 weeks, and interestingly, two periods had oc-
curred after sporting activities (boating on a rough
sea and cross-country mountain biking). On exami-
nation, an ageotropic horizontal nystagmus was ob-
served during the HC maneuvers that spontaneously
disappeared a few days later. A brain MRI scan was
normal.
To summarize, the patient presented a right-sided
PC BPPV, cured by an Hpley maneuver, associated
with an ageotropic HC BPPV the side of which was
difficult to assess, inasmuch as there was a simulta-
neous left labyrinth concussion.
Case 3. A 49-year-old woman was hospitalized
after a motor vehicle accident on March 13, 2002.
She had a previous history of depression, migraine,
and cervical discopathy (C5-6 level) and had under-
gone surgery for left-sided otospongiosis in 1983.
At the time of the accident, she suffered a few min-
utes' loss of consciousness, and her head trauma was
evident from a voluminous right facial hematoma.
The main complaint was pronounced vertigo during
all types of head movement, particularly when roll-
ing over in bed, although she also complained of fa-
cial and cervical pain. Facial and head CTT scans were
normal, as was a Doppler ultrasonogram of the su-
108
Bertholon et al. Vertigo Following Head Trauma
pra-aortic vessels.
She was first seen in our department on March
20. There was no nystagmus during fixation, under
Frenzel glasses, or after head-shaking. Romberg and
Fukuda tests revealed only a slight instability with
no lateralization. Carefully performed positional ma-
neuvers wereconclusiveot the diagnosis (Fig 3). The
right Dix-Hallpike maneuver triggered a paroxysmal
clockwise rotatory-upbeat ny.stagmus. The left Dix-
Hallpike maneuver triggered a paroxysmal counter-
clockwise rota tory-upbeat nystagmus. The right HC
maneuver induced a right horizontal nystagmus, and
that on the left side induced a violent left horizontal
nystagmus. The findings ofthe neurologic examina-
tion were otherwise normal. Pure tone audiometric
findings were normal on the right side and showed a
mixed hearing loss on the left side, probably the re-
sult of the previous olospongiosis, as the patient had
had no recent hearing complaint. The patient was
thought to be suffering from bilateral PC BPPV as-
sociated with a left geotropic HC BPPV, for which
she was asked to sleep on her right side.'- She was
reassessed on April 2 and had negative HC maneu-
vers on both sides. The right Dix-Hallpike maneu-
ver still triggered a clockwise rotatory-upbeat nys-
tagmus, and the left Dix-Hallpike maneuver a strong
counterclockwise rotatory-upbeat nystagmus. An Ep-
ley maneuver was performed for the left side, but this
proved to be ineffective, as the left Dix-Hallpike ma-
neuver remained positive on April 9. Another Epley
maneuver was performed, this time successfully, as
the left Dix-Hallpike maneuver was negative half an
hour later. On April 24, only the right Dix-Hallpike
maneuver triggered a clockwise rotatory-upbeat nys-
tagmus, for which an Epley maneuver was performed,
and all positional maneuvers were negative on May
7. Videonystagmography revealed a bilateral sym-
metric caloric hyperretlexia and a slightly deranged
pursuit. The brain MRI findings were normal, and
the cervical MRI reveaied only the previous cervi-
cal discopathy. The patient was reassessed several
times during a 2-year follow-up and showed no clear
recurrence of positional vertigo or nystagmus.
To summarize, the patient presented bilateral PC
BPPV. cured by the Epley maneuver, associated with
a left HC BPPV. cured by prolonged positioning on
the right side.
DISCUSSION
The head trauma in our patients could be consid-
ered minor in patients 2 and 3, because the posttrau-
matic amnesia lasted for less than 3 hours and there
was no skull base fracture, and could be considered
moderate in patient 1, who presented with a skull base
fracture.' ^-' '^ The head trauma was directly responsi-
ble for the vertigo, because the positional vertigo oc-
curred shortly after the injury and was associated with
a positional nystagmus observed within 2 weeks of
the injury.'^'^"' Head trauma is a well-known cause
of vertigo due to lesions affecting the labyrinth, the
vestibular nerve, the brain stem, and/or the cerebel-
lum.'^-' Lesions ofthe labyrinth are the most com-
mon'^'"^ and can induce various types of vertigo,
ranging from a spontaneous and prolonged vertigo
associated with caloric hyporefiexia or aretiexia in
the context ofa labyrinth fracture or concussion-"''
to a brief positional vertigo related to BPPV caused
by abnormal displacement of otoconial debris.'-'^-'-^^
Our 3 patients essentially complained of positional
vertigo and showed positive findings on positional
maneuvers consistent with a diagnosis of BPPV. One
patient (case 2) also had spontaneous vertigo that
lasted for a few days and was associated with right-
beating nystagmus, left truncai deviation, and left
caloric hyporefiexia all features that were com-
patible with an additional left labyrinthine concussion
in the absence of labyrinthine fracture on CT scan.-"-'
None of these 3 patients had neurologic symptoms
or signs that were suspicious for a central lesion, and
the normality ofthe brain CT and/or MRI scans did
not indicate a brain stem or cerebellar lesion.
These 3 patients presented with a complex posi-
tional nystagmus that could only be interpreted as a
combination of PC BPPV and HC BPPV. We believe
that this diagnosis was possible for two reasons. First,
we are extremely attentive to the direction ofthe po-
sitional nystagmus, which is the key finding that dis-
tinguishes a PC BPPV from an HC BPPV, as, accord-
ing to Ewald's first law, the nystagmus beats in tbe
plane of tbe affected canal.''The nystagmus is there-
fore essentially rotatory for a Pfj BPPV, although
there is an additional upbeat component, and is hori-
zontal for an HC BPPV Second, we systematically
perform the Dix-Hallpike maneuver, as well as the
HC maneuver, paying particular attention to the ma-
neuver that provokes the vertigo and nystagmus. The
Dix-Hallpike maneuver is the optimal maneuver for
a PC BPPV,' while the HC maneuver is tbe optimal
maneuver for an HC BPPV.--^ although a positional
maneuver is not specific to a semicircular canal.-'-*
We believe it is essential to perform both maneuvers,
and not only the Dix-Hallpike maneuver, as was
proved necessary for the accurate diagnosis of 2 of
our patients. In patient 1 (Fig I), it would have been
impossible to draw the necessary conclusions from
the rotatory-upbeat nystagmus followed by horizontal
nystagmus that was seen during the Dix-Hallpike ma-
neuver, and indeed, it was the occurrence ofa pure
horizontal direction-changing positional nystagmus
Bertholon et al. Vertigo Following Head Trauma 109
during the HC maneuvers that suggested the combi-
nation of PC BPPV and HC BPPV. In patient 3 {Fig
3), the HC BPPV was not triggered by the Dix-Hall-
pike maneuver, and the diagnosis of an HC BPPV
associated with a PC BPPV would have been missed
if the HC maneuver had not been systematically per-
formed.'-^
In all 3 patients, the diagnosis of BPPV was further
confirmed by the favorable outcome. The PC BPPV,
unilateral or bilateral, was successfully treated with
the Epley maneuver.'-^ Recovery from the HC BPPV
was also rapid. In patient 3, who had a geotropic HC
BPPV with the lesioned side easily recognizable, the
recovery was due to the effectiveness ofthe Vannuc-
chi maneuver.' - The Vannucchi maneuver is a simple
and well-tolerated procedure that we use first in geo-
tropic HC BPPV, reserving the Lempert maneuver-^
for when this first method fails. In patients 1 and 2,
with an ageotropic HC BPPV, the lesioned side could
not be formally ascertained, and no treatment was
applied right away. This decision was motivated by
the absence of consensus on the treatment of an ageo-
tropic HC BPPV,'^'''-^'*^ altbough different methods
have been proposed either to immediately cure the
ageotropic HC BPPV^-^or to transform an ageotropic
HC BPPV into a geotropic one.'-" However, the fact
that recovery occurred within 2 weeks in patient 2
and in 1 month in patient 1 corroborates that sponta-
neous recovery is often more rapid for HC BPPV,
whether ageotropic'''^^ or geotropic,** than for PC
BPPV, which takes an average of 11 weeks after di-
agnosis.-"* The recurrence of BPPV, as seen in patient
2, is a common phenomenon in both HC BPPV and
PC 2
From a physiopathological viewpoint, it is easy to
conceive that any head trauma that causes PC BPPV^
or HC BPPV-^-*-^-^ could also induce a combined form
involving both canals. Indeed, it has been demon-
strated tbat bilateral PC BPPV is more prevalent in
po.sttraumatic cases than in idiopathic cases.'*' Schu-
knecht-' proposed that head trauma could disrupt the
utricular otolithic membrane and release into the en-
dolymph otoconial debris that are then free to settle
in the PC and/or the HC. According to this theory^'
and our own experience, we would hypothesize that
the greater the number of canals involved in BPPV,
especially when there is bilateral involvement, the
greater the likelihood that the origin is traumatic.
In conclusion, every patient who complains of po-
sitional vertigo should undergo two positional tests
the Dix-Hallpike maneuver and the HC maneuver
in order to search for PC BPPV, HC BPPV, and
the association of both. Early diagnosis and treatment
may help reduce the postconcussion syndrome.
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