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Resumen Antecedentes y objetivo La migrana vestibular (MV) es una de las causas de sindrome vestibular episodico. Existen muchos farmacos disponibles para su profilaxis y actualmente su eleccion se realiza mayoritariamente segun las comorbilidades del paciente. El objetivo de este articulo es medir la concordancia de un grupo de otorrinolaringologos en la eleccion de profilaxis y evaluar el papel que ejerce sobre esta un algoritmo asistido para la eleccion de profilaxis. Material y metodo Las historias clinicas de 10 pacientes con MV fueron ofrecidas a 10 otorrinolaringologos, a los que se les pidio que seleccionasen para cada paciente el farmaco que considerasen mas adecuado entre 5 opciones posibles. Se calcularon los indices κ de Fleiss entre los 10 otorrinolaringologos solos y se recalcularon incluyendo al algoritmo como undecimoevaluador, y la κ de Cohen entre cada otorrinolaringologo y el algoritmo. Se ofrecio a los otorrinolaringologos la opcion de cambiar su respuesta tras conocer la respuesta del algoritmo, y ambos indices fueron calculados nuevamente. Resultados El indice κ de Fleiss fue de 0,302. Dicho indice se elevo a 0,343 tras introducir al algoritmo como evaluador. Tras ofrecer las soluciones propuestas por el algoritmo, se mejoro la κ de Cohen en 9 de los 10 evaluadores y la κ de Fleiss subio a 0,711. Conclusiones La concordancia entre otorrinolaringologos para elegir profilaxis para la MV se define como «justa». Las respuestas del algoritmo para la eleccion de profilaxis se situaron proximas a la opinion media de los otorrinolaringologos, elevando la concordancia entre ellos a «sustancial».

Benign paroxysmal positional vertigo (BPPV) is the most frequent type of vertigo. The treatment of canalithiasis of the posterior semicircular canal consists in performing a particle-repositioning maneuver, such as the Epley maneuver (EM). However, the EM is not effective in all cases. The objective of this study is to identify risk factors, which predict the EM failure, among the clinical variables recorded in anamnesis and patient examination. This is an observational prospective multicentric study. All patients presenting with BPPV were recruited and applied the EM and appointed for a follow-up visit 7 days later. The following variables were recorded: sex, age, arterial hypertension, diabetes, hyperlipidemia, smoking habit, alcohol consumption, migraine, osteoporosis, diseases of the inner ear, previous ipsilateral BPPV, previous traumatic brain injury, previous sudden head deceleration, time of evolution, sulpiride or betahistine treatment, experienced symptoms, outcome of the Halmagyi maneuver, laterality, cephalic hyperextension of the neck, intensity of nystagmus, intensity of vertigo, duration of nystagmus, occurrence of orthotropic nystagmus, symptoms immediately after the EM, postural restrictions, and symptoms 7 days after the EM. Significant differences in the rate of loss of nystagmus were found for six variables: hyperlipidemia, previous ipsilateral BPPV, intensity of nystagmus, duration of nystagmus, post-maneuver sweating, and subjective status. The most useful significant variables in the clinical practice to predict the success of the EM are previous BPPV and intensity of nystagmus. In the other significant variables, no physiopathological hypothesis can be formulated or differences between groups are too small.

Incidenza della vertigine parossistica benigna bilaterale e monolaterale in caso di positività alla manovra Dix-Hallpike a destra e sinistra: modello basato sul verso del nistagmo rotatorio.Frequentemente nella pratica clinica si valutano pazienti che mostrano alle manovre di Dix-Hallpike (DHM), verso destra e verso sinistra, il nistagmo tipico della vertigine posizionale parossistica benigna (BPPV). In questi casi la BPPV può essere unilaterale o bilaterale. Lo scopo del presente studio è quello di descrivere l’incidenza della BPPV unilaterale e bilaterale, quando entrambe le DHM sono positive, considerando il verso della componente torsionale del nistagmo. In questo studio prospettico multicentrico i pazienti sono stati suddivisi in tre gruppi: pazienti con solo una DHM positiva (gruppo di controllo, CG), pazienti con DHM positiva bilateralmente e con nistagmo battente nello stesso verso evocabile in entrambe le manovre (gruppo stesso verso, SSG), pazienti con DHM positiva bilateralmente e con nistagmo avente componente torsionale con verso opposto nelle due manovre (gruppo verso opposto, OSG). La manovra di Epley (EM) è stata condotta su tutti i pazienti. Considerando i risultati ottenuti dalla EM e il tasso di risoluzione della BPPV nel CG, è stato sviluppato un modello predittivo dell’incidenza della BPPV unilaterale e bilaterale negli SSG e OSG. Il CG comprendeva 234 pazienti, 20 erano inclusi invece nel SSG e 23 nell’OSG. Il modello ha stimato che la percentuale di BPPV unilaterale ammonterebbe a 89,5% nel SSG e 38,7% nel OSG. In conclusione, se entrambe le DHM sono positive, la BPPV può essere sia unilaterale che bilaterale. Se la componente torsionale dei nistagmi batte nello stesso verso, è più probabile che la BPPV sia unilaterale; se invece tale componente ha verso opposto alle DHM, le due condizioni possono considerarsi ugualmente probabili.Patients presenting with nystagmus indicative of benign paroxysmal positional vertigo (BPPV) during the left and the right Dix-Hallpike manoeuvres (DHMs) are frequently seen in clinical practice. In such cases, BPPV may be unilateral or bilateral. The aim of this study is to describe the incidence of unilateral and bilateral BPPV when both DHMs are positive, taking into account the sense of the torsional component of nystagmus. This is a prospective multicentre study. BPPV patients were classified into three groups: patients with only one positive DHM (control group, CG), patients showing positive bilateral DHM with nystagmus in the same sense in both DHMs (same sense group, SSG) and patients showing positive bilateral DHM with the torsional component of nystagmus beating in opposite senses in each DHM (opposite sense group, OSG). Only one Epley Manoeuvre (EM) was performed on all patients. Based on the ipsilateral result of the EM, the contralateral result of the same EM and the BPPV resolution rate in the control group, a model was developed to predict the incidence of unilateral and bilateral BPPV in the SSG and the OSG. There were 234 patients in the control group, 20 in the SSG and 23 in the OSG. The model estimated that the percentage of unilateral BPPV would be 89.5% in SSG and 38.7% in OSG. Using these findings, we conclude that when both DHMs are positive, BPPV may be unilateral or bilateral. If the torsional components of both nystagmuses beat in the same sense, it is more likely to be unilateral BPPV. If the torsional components beat in opposite senses, both situations can be considered equally likely.

OBJECTIVES To compare the outcome of the Epley maneuver (EM) in benign paroxysmal positional vertigo of the posterior canal (CSP-BPPV) depending on the definition used for recovery. DESIGN Multicenter observational prospective study. SETTING Otoneurology Units of 5 tertiary reference hospitals. PARTICIPANTS All patients presenting with unilateral CSP-BPPV assisted for 1-year period. EXCLUSION CRITERIA Spontaneous nystagmus, positive McClure-Pagnini maneuver, positive bilateral Dix-Hallpike maneuver (DHM), positive DHM for vertigo but negative for nystagmus and atypical nystagmus. MAIN OUTCOME MEASURES Response to EM was measured after 7 days in 3 different outcomes: disappearance of nystagmus during the DHM in the follow-up visit, disappearance of vertigo during the DHM and general status (GS) during daily life activities. RESULTS 264 patients were recruited (68 male/166 female, mean age 62 years). After the EM, nystagmus disappeared in 67% of them, vertigo in 54% and 36% were asymptomatic in their daily life. These outcomes were strongly correlated, but they were not concordant in a clinically significant group of cases; only the 26% of patients met all of them. The healing process follows the next sequence: negativization of positional nystagmus, then disappearance of positional vertigo and, finally, the improvement of GS during daily life activities. CONCLUSION Nowadays, healing criteria for the resolution of an PSC-BPPV episode have not been specifically defined yet. Provided that other otoneurological disorders have been ruled out, the next resolution criterion is proposed: absence of nystagmus and specifically during control DHM and disappearance of symptoms during daily life activities.