VIDEO CASE STUDY: Biomechanics of Gans Repositioning Maneuver (GRM) for a Little Person with bilateral PC-BPPV

BPPV is among the most common causes of vertigo for children and adults. Canalith Repositioning Maneuvers (CRM) utilizing Epley, Gans or Semont methods or modifications have shown to be highly efficacious for all populations regardless of the specific protocol. In previous Gans Blogs we have shown treatment of BPPV for several adolescents with physical limitations… Continue Reading »

VIDEO CASE STUDY: cVEMP- Best Test for Infants

By age 3-4 months, infant’s neck musculature is typically strong enough to provide sufficient support to allow for reliable use of cervical Vestibular Myogenic Potentials, (cVEMP). A question may be asked, why test a baby? The literature clearly shows the co-morbidities of sensorineural hearing loss (SNHL) and vestibular abnormalities. Therefore, it is our opinion and… Continue Reading »

VIDEO – CASE STUDY: Gans Repositioning Maneuver (GRM): Treatment of Bilateral PC-BPPV Post Head Trauma

Head trauma with or without concussion is a well-known cause of BPPV in both children and adults. More importantly, BPPV secondary to head trauma has been associated with increased bilateral and multiple canal involvement as well as a higher recurrence rate. The benefit of the GRM and Semont Liberatory Maneuver (SLM) when treating bilateral cases,… Continue Reading »

VIDEO: CASE STUDY – Treatment of sub-clinical HC-BPPV in a 15 year-old male post basilar skull fracture and concussion

The literature and this author has presented extensively on the incidence of BPPV post head trauma in children and adults, with and without concussion. Trauma induced BPPV tends to be more bilateral and it is not unusual to involve multiple canals. Often times, because the severity of the head trauma is considerable, BPPV may be… Continue Reading »

CASE STUDY: Home-based Vestibular Rehabilitation (VRT) Program: Measuring Outcomes with vHIT and Dynamic Visual Acuity Tests

Vestibular Rehabilitation Therapy (VRT) is well established as the gold standard for the non-medical management of chronic non-compensated unilateral vestibulopathy secondary to acute onset otologic conditions or vestibular migraine. The question often arises whether a home-based program can provide successful outcomes for those patients unable or unwilling to participate in a clinician directed program in… Continue Reading »

VIDEO: Video Head Impulse Test (vHIT) with Children

The vHIT is easily and reliably performed with children. Vestibular evaluation of children can often be somewhat complicated if the practitioner does not have access to a rotary chair or VEMP. The use of the recently developed vHIT offers a simple, highly reliable, non-invasive and high sensitivity protocol to quickly evaluate children. The use of… Continue Reading »

VIDEO- Video Head Impulse Test (vHIT) Has High Diagnostic Sensitivity and Provides VRT Outcome Validation

  Clinicians and therapists have historically been limited by the constraints of caloric testing, which is a very poor indicator of comprehensive VOR function due to its testing of only the horizontal canals at ultra low-frequency sensitivity (.003Hz). More importantly, caloric testing cannot provide the status of the patient’s compensation. For patients with mid-high frequency… Continue Reading »

VIDEO: VRT with Diagnosis Based Strategies using Hybrid Protocols

Vestibular Rehabilitation Therapy (VRT) is recognized as the gold standard for the non-medical, non-surgical management of this often-debilitating condition. Its usefulness has been demonstrated with children to adults, military pilots, and even astronauts, for whom its scientific advancement in the 1980’s was intended. It is most useful for patients who may have experienced any of… Continue Reading »

VIDEO: Basilar Invagination in Osteogenesis Imperfecta or BPPV ?

  This charming 14 year-old female with Osteotogenesis Imperfecta (OI), who is pre-pubescent, has a radiographically confirmed basilar invagination for many years. In addition, she has experienced over 50 fractures related to her OI condition. There is neither a history of migraine, nor a familial link with mother and maternal grandmother negative for report of… Continue Reading »

VIDEO: Horizontal Canal BPPV (HC-BPPV)- Contraindication to Self Treatment

  The incidence of Horizontal Canal (HC) involvement in our 20 years of experience treating almost 11,000 BPPV cases has been its association either with a migration during a CRM treatment, or inadvertently during the patient’s normal everyday activities. Our data (Roberts and Gans, 2008) is consistent with that reported by other investigators with a… Continue Reading »

VIDEO- Treatment of Patient with Mobius Syndrome and Phobic Postural Vertigo (PPV): Part II

    In Part I, we saw the 38 year-old female patient, learned the history and discussed assessment options for an individual with Mobius Syndrome. The key now for successful treatment of the Phobic Postural Vertigo, is how we utilized a combination of Cognitive Behavioral Therapy (CBT) and Vestibular Rehabilitation Therapy (VRT). The CBT will… Continue Reading »

VIDEO – Vestibular Assessment of Patient with Mobius Syndrome Phobic Postural Vertigo: Part I

Mobius Syndrome is a rare congenital genetic disorder involving underdevelopment of cranial nerves VI and VII.  Mobius includes aspects of facial paralysis and inability to have patterns of facial expression. Since the majority of classic vestibular assessment protocols e.g. VNG, Vorteq, Rotary Chair utilize the VOR, how then do you evaluate a patient for vestibular… Continue Reading »

VIDEO – Post-Traumatic BPPV May be Complex

According to the NIH, each year, 1.7. Million Americans experience a concussion also called mild Traumatic Brain Injury (m-TBI). Researchers have reported a wide variability of the condition in individuals with head-impact induced BPPV than those with otologic or idiopathic onset. The nature of the mTBI may be sports related, motor vehicle accidents (MVA), military… Continue Reading »

Pediatric Balance Examination

At AIB, pediatric balance evaluation is a critically important diagnostic service to the medical and rehabilitation community. Evaluation may be conducted with neonates/infants as young as 3 months of age. The evaluation will include both behavioral and electrophysiological evaluation, depending on the age-appropriateness of each component. Even without advanced instrumentation e.g. rotary chair and VEMP,… Continue Reading »

VIDEO: Balance Assessment of Child with Hemifacial Microsomia (HFM) and Delayed Neuromotor Function

Case Study: a 3 year 8 month old male referred for balance assessment by a pediatric ENT. The child has a right-sided hemifacial microsomia (HFM). It has been determined from CT scan that inner ear anatomical structure is intact. Pre, peri and post birth history is unremarkable. He is the middle child (siblings are 6… Continue Reading »

Balance Dysfunction in Children Secondary to Otitis Media with Effusion

Although there is not an abundance of literature on pediatric vestibular issues, otitis media with effusion (OME) has been reported in the literature as a cause of balance dysfunction in children. This may be further complicated by other co-morbidities, such as BPV of Infancy or in children with documented congenital sensorineural hearing loss secondary to… Continue Reading »

VIDEO – Video Head Impulse Test (VHIT)

Background: The visualization of corrective saccades as a highly sensitive bedside examination of a peripheral vestibular deficit has been well reported in the literature. The “head thrust” test as described by Halmaygi and Curthyos (1988) and others has shown to be excellent bedside test in revealing status of non-compensated or active labyrinthine conditions including ear… Continue Reading »

VIDEO – mTBI/Concussion and Oscillopsia: The importance of dynamic visual acuity (DVA) testing

mTBI, more commonly known as concussion, is well reported in both civilian and military literature, but has gained significant public attention due to the interest of sports related head trauma. The American Academy of Neurology has published (April, 2013) an updated position statement on this increasingly common form of head impact regarding its guidelines and… Continue Reading »

VIDEO- Migrainous Positional Vertigo (MPV): Ear or Brain?

Roberts, Gans and Kastner (2006), von Breveren (2004) and Neuhauser (2001) have all published articles about MPV. The condition is seen almost exclusively in post-menopausal females with history of migraine. At AIB we have seen dozens of patients ranging from 39 to 74 years of age. All had a history of migraine (IHC, 2004) since… Continue Reading »

VIDEO- Conversion Disorders in the Balance Clinic

Patients with Dissociative or Somatoform disorders commonly referred to as Conversion Disorders are often seen in balance centers due to their motor control issues and hypersensitivities to motion, light, sound etc.  Conversion disorder is classified as a psychiatric disorder and is usually seen in individuals with a long-standing history and well-documented personality disorders such as… Continue Reading »

VIDEO – CTSIB Sensitivity Improved with Head Shake

First described by Shumway-Cook and Horak in 1986, the Clinical Test of Sensory Integration of Balance ( CTSIB ) has withstood the test of time as one of the most sensitive and cost-effective low technology assessment tools for a non-compensated vestibular condition. This author has utilized the protocol in testing over 100,000 patients and it… Continue Reading »

VIDEO – Vertebral Artery Insufficiency (VBI) Case Study

The neurology and physical therapy literature has long-identified VBI as an origin of vertigo, nystagmus, diplopia and other focal neurological symptoms. The vertebral arteries are responsible for blood supply to the peripheral and central vestibular mechanisms, pons, cerebellum and visual cortex, thus explaining the associated symptoms when there is a compression, stretching or dissection. This… Continue Reading »

VIDEO – BPPV-PC Nystagmus: Watch the Contralateral Eye

In this video, the patient is placed in a left side-lying – modified Hallpike with left ear down. You will clearly see the upbeat torsional nystagmus (stronger vertical component than torsional as is commonly seen) associated with the left ear PC-BPPV. When watching for BPPV mediated nystagmus, regardless with direct observation or with VOG/VNG, it… Continue Reading »

VIDEO – Vestibular Evoked Myogenic Potentials (cVEMPs) – 6 Pediatric PEARLS

At AIB we perform and obtain reliable Vestibular Evoked Myogenic Potentials (C-VEMPs) on infants and children quite easily. Here are several videos, which illustrate some techniques. It may vary from the infant laying on the parent’s lap, or resting comfortably, to collection during a righting reflex. The modifications we use are based on infants-child’s age…. Continue Reading »

VIDEO – Gans Repositioning Maneuver (GRM) with Bed Roll: Left PC-BPPV

The Gans Repositioning Maneuver GRM, developed in 2000, has been described in the literature and textbooks as a hybrid maneuver; particularly useful with individuals with poor or limited mobility and for those that neck hyperextension is contraindicated. An additional technique of use of a sheet or towel to facilitate a smooth and effortless bed roll, used… Continue Reading »

VIDEO – CHARGE Syndrome 14 month old

We recently saw this 14 month-old female for a vestibular evaluation from the UAE. She has been undergoing therapy since age 3 months. As can be seen, developmentally there is significant motor milestone delay and she is at a 2 month-old motor function without neck stabilization of head and trunk. This presents a challenge in… Continue Reading »

VIDEO – BPV of Childhood (BPVC)

BPV of Childhood with torticollis in 20 month-old: Evaluated with VEMP and Behavioral Protocols The most common cause of dizziness (35%) in children is one of the six categories of migraine (IHC, 2004). Vestibular Evoked Myogenic Potentials (VEMP) is an ideal protocol when evaluating vestibular function in infants and young children (Gans R., 2012). VEMP… Continue Reading »

VIDEO – Pediatric Vestibular Evaluation with Special Population

12 year-old female with Downs Syndrome evaluated by AIB’s Clinic Coordinator, Dr. Mary Kim, using VORTEQ to assess VOR status. Pediatric vestibular testing, just as with all child-directed audiologic protocols, must accommodate the child’s specific needs. This child’s family was concerned about some recent behavioral changes. Based on possible concerns of “dizziness” the pediatrician and… Continue Reading »

VIDEO – PC-BPPV Nystagmus: It’s not so rotary after all

In this video we see a strong and clear nystagmus consistent with a right ear (PC-BPPV Nystagmus: It’s not so rotary after all) PC-BPPV.  The nystagmus, while described as “rotary-torsional”,  will actually have a more visible upward and oblique movement than may be anticipated by new practitioners. Often times, practitioners new to BPPV are perplexed… Continue Reading »

VIDEO – Horizontal Canal (HC)-BPPV Conversion

VIDEO- Right ear HC-with the patient laying on her left side produces an “ageotropic ” nystagmus. In this patient, we see the fast phase beating towards the involved right HC. When she laid on her right side the nystagmus was “geotropic” more intense with stronger vertigo.   The presence of a transient but long-lived positional… Continue Reading »

VIDEO – Pediatric Vestibular Dysfunction

It is estimated that over 500 syndromes and non-syndromes are known to have audiovestibular expressivity (Pikus, 2002). Some well-recognized syndromes such as Waardenburg, actually have a greater incidence of vestibular than auditory expressivity. In addition, BPV of Infancy, one of the six categories of Migraine (IHC, 2004), a genetic neurological disorder, is the leading cause… Continue Reading »

VIDEO: Headshake Nystagmus Helps Determine Status of Compensation

The introduction of a headshake protocol within a bedside examination or VNG is often useful in revealing an active or yet uncompensated vestibulopathy within the frequency of the VOR. The protocol is performed with the patient seated, however its sensitivity will be enhanced when performed in a lateral body position. The caveat is that the… Continue Reading »

VIDEO: Eccentric Gaze Nystagmus: Importance in bedside Exam

Observation of spontaneous nystagmus is uncommon unless you are attending to a patient within several hours or days of an acute labyrinthine attack or suffering a CNS lesion. It may be even more difficult at bedside/chairside without the use of VOG goggles.  For those practitioners less familiar with direct observation of nystagmus, eccentric gaze is… Continue Reading »

Subdural Hemotoma May Mimic BPPV Post Head Trauma

We see a significant number of patients with BPPV secondary to even relatively minor head impacts. Falls from bicycles, hitting their heads on night stands, golf carts, car doors etc., that do not force patient to go to ED or seek immediate medical attention. What they consider just a “ bad crack on the head”… Continue Reading »

Vestibular Migraine Post Hysterectomy

Migraine effects far more females than males, 3:1 and has long been recognized to have hormonal triggers. Females typically experience the onset of migraine (with and without aura) at puberty and often see a reduction in symptoms post menopause. The literature suggests however, that post hysterectomy (surgical menopause) approximately 45% of patients’ report that their… Continue Reading »

VIDEO: HC-BPPV in 16 year old male with Spina bifida

A 16 year-old male with a severe form of Spina bifida (lower body paralysis, AV shunt, and thoracic cavity) was referred to AIB by a pediatric otolaryngologist for evaluation of positional vertigo. There was no precedent otologic or acute onset episode, nor any auditory complaints. The provoked vertigo lasts only seconds, without any other associated… Continue Reading »

VIDEO: Positional Vertigo and Nystagmus in Multiple Sclerosis (M.S.)

Positional vertigo with and without nystagmus may have either otologic or neurologic origins. The most common otologic condition we associate with transient vertigo and nystagmus lasting seconds is of course BPPV- PC or HC. In those cases, however, when it is not transient, we must consider a neurological origin. We are often asked to evaluate… Continue Reading »

Brain vs. Ear…does it make a difference in Vestibular Rehabilitation (VR) Protocols and Efficacy?

Does the location of the lesion effect Vestibular Rehabilitation treatment protocols and outcomes? Why do some patients have spontaneous central compensation and others do not? Why do some patients have a faster and more successful recovery than do others? Although, we have recognized the location of the lesion as a critical variable, thanks to the… Continue Reading »

Benign Paroxysmal Positioning Vertigo (BPPV): Post Head Trauma including Impact, Concussion and Whiplash

1.7 million Americans suffer concussions or mild TBI (mTBI) each year according to the Centers for Disease Control (2012). Almost one-half million ER visits as a result of head trauma each year are by children 14 years of age or younger. Older adolescents age 15-19 years and those aged 65 years and older are the… Continue Reading »

VIDEO: Cardiogenic vs. CNS Downbeat Nystagmus (DBN)

  Downbeat Nystagmus (DBN) is among the most common forms of centrally mediated positional provoked nystagmus.  It may also be accompanied by a transient dizziness or vertigo. It is typically only seen in ears as the vertical component in an AC-BPPV or with stimulation (acoustic) of a Superior Canal Dehiscence. Although vertigo is typically associated… Continue Reading »

(video) Long–term benefit of Gans Repositioning Maneuver (GRM) and impact of non-labyrinthine medical co-morbidities in balance function.

Patient C.L. a 92 year old female is seen at AIB for complaints of imbalance, falls and independent ambulation. She uses a wheeled walker. The patient was last seen in 2001 for a right ear PC-BPPV and successfully treated with GRM. At that time there were no reports of imbalance, hearing loss, or vision issues…. Continue Reading »

Migraine Anxiety Related Dizziness (MARD)

Described by Furman et al (2005) we see this condition in an increasing number of non-labyrinthine cases of internalized dizziness with heightened motion and visual disturbance.  In fact, at AIB, in just the past 10 days we have seen a 49 year old female speech pathologist and a 33 year old female computer programmer. All… Continue Reading »

Vertebral Basilar Insufficiencies (VBI) vs. non-classic BPPV

Current Neurology literature continues to present cases of vertebral basilar insufficiencies (VBI), vertebral artery ischemia (VA stroke) and cervical artery dissections (Choi JH et al, 2011, Kim BM et al 2011, Schievink WI and Debette S, 2011, Volker W et al, 2011). This should be of particular interest to clinicians examining patients with complaints of positional vertigo;… Continue Reading »

Chronic dizziness and nausea post subarachnoid hemorrhage (SAH)

This week at AIB a 52 year old female, post subarachnoid hemorrhage (SAH), was referred with chronic debilitating dizziness, nausea and emesis . Read the following case history, findings, impressions, plan and current research and the successful outcome. History: This week at AIB a 52 year old female was referred with chronic dizziness and nausea… Continue Reading »

New Research Indicates Vestibular Migraine May Persist for Years

Vestibular migraine (VM) is among the most common causes of vertigo. Numerous studies have shown that the origin is within the central vestibular structures rather than the labyrinth itself,  producing abnormal findings of both central and peripheral patterns including; vertical or torsional spontaneous nystagmus, gaze evoked nystagmus, and positional vertigo and nystagmus mimicking “non-classical” BPPV…. Continue Reading »