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Case Report/Case Series |

Persistent Spontaneous Nystagmus Following a Canalith Repositioning Procedure in Horizontal Semicircular Canal Benign Paroxysmal Positional Vertigo

Kyung Min Ko, MD1; Mee Hyun Song, MD, PhD1; Ji Hong Kim, MD1; Dae Bo Shim, MD1
[+] Author Affiliations
1Department of Otorhinolaryngology, Myongji Hospital, Goyang, South Korea
JAMA Otolaryngol Head Neck Surg. 2014;140(3):250-252. doi:10.1001/jamaoto.2013.6207.
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Importance  Nystagmus can occur spontaneously from multiple causes. Direction-changing positional nystagmus on the supine roll test is a characteristic clinical feature in horizontal semicircular canal benign paroxysmal positional vertigo. One of several mechanisms of spontaneous nystagmus is plugging of the otoconia, which has been described as a canalith jam.

Observations  We evaluated a 52-year-old woman with a history of geotropic variant of horizontal semicircular canal benign paroxysmal positional vertigo on the right side who had been treated with a modified Lempert maneuver 3 months earlier. The patient had persistent spontaneous nystagmus, despite a positional change after the canalith repositioning procedure. A bithermal caloric test result demonstrated unilateral canal paresis on the right side. The following day, the patient’s symptoms and nystagmus had subsided. On a repeated bithermal caloric test, a normal response was demonstrated on both sides.

Conclusions and Relevance  To our knowledge, this is the first report of a case that shows on video persistent nystagmus findings consistent with a canalith jam. We discuss a possible mechanism underlying this phenomenon.

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Figures

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Figure 1.
Mechanism of Plugging of the Right Horizontal Semicircular Canal With the Patient Lying on the Right Side

The movement of the otoconia forms a plug (long curved arrows), resulting in complete impaction in the narrowest part of the canal, which may have been aggravated by the patient’s position after physiotherapy. The white arrowhead indicates the affected ear, and the black arrowhead indicates the patient’s nose.

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Figure 2.
Possible Mechanism of Persistent Spontaneous Nystagmus With a Canalith Jam

Complete impaction may result in a positive endolymph pressure (long curved arrow) that could induce prolonged utriculopetal deviation of the cupula (short straight arrow). The white arrowhead indicates the affected ear, and the black arrowhead indicates the patient’s nose.

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Multimedia

Video 1.

The Presence of Nystagmus Suggests Geotropic Variant of Horizontal Semicircular Canal Benign Paroxysmal Positional Vertigo on the Left Side

The initial Dix-Hallpike test and supine roll test induced geotropic direction-changing horizontal nystagmus, which was more severe on the left side. Head-bending nystagmus (the head is bent 30° forward in the neutral sitting position) and lying-down nystagmus (the patient lies supine with the head flexed 30° forward) were not observed. Immediately after the initial positional test, a repeated right supine roll test was performed, which revealed right horizontal geotropic nystagmus with an amplitude similar to that seen during the left supine roll test. On a repeated head-bending nystagmus test, subtle right horizontal nystagmus was demonstrated.

Video 2.

The Presence of Nystagmus Suggests a Canalith Jam of the Horizontal Semicircular Canal on the Right Side

Spontaneous horizontal nystagmus beating toward the right side that persisted in all positions. Head shaking did not exacerbate the intensity of the right-beating nystagmus.

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