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Highlights Video head impulse testing and vestibular evoked myogenic potentials show that acute vestibular neuropathy is heterogeneous. Peripheral vestibular pathway vulnerability is approximately inversely correlated with its proportion of afferent fibers. Caloric testing, while useful, should no longer be considered the gold standard for diagnosing acute vestibular neuropathy.

SDC Video Link: http://links.lww.com/MAO/B86.

Objective We aimed to describe the clinical features of the apogeotropic variant of horizontal canal benign paroxysmal positional vertigo (HC BPPV-AG) in a cluster of patients with restrictive neck movement disorders and a new therapeutic manoeuvre for its management. Methods In a retrospective review of cases from an ambulatory tertiary referral center, patients with HC BPPV-AG in combination with neck movement restriction that prevented any classical manual repositioning procedure or who were refractory to canalith repositioning manoeuvres, were treated with a new manoeuvre comprised of sequential square-wave pattern of head and body supine rotations while nystagmus was being monitored, until either an apogeotropic to geotropic conversion or resolution of the nystagmus was observed. Results Fifteen patients were studied. All but one [14/15 cases] showed a positive therapeutic response to the repositioning procedure in a single session. In two cases, a direct relief of vertigo and elimination of nystagmus was observed without an intermediate geotropic phase. Although in three patients the affected ear was not initially identified, it was ultimately identified and successfully treated by the square wave manoeuvre in all of them. Conclusions The square-wave manoeuvre is an alternative for HC BPPV-AG treatment in either cases with neck restriction, where the affected side is not well identified at the bedside or when other manoeuvres fail to resolve the HC BPPV-AG.

Objective: To examine the high frequency horizontal vestibular ocular-reflex (hVOR) during acute attacks of vertigo in Menière's disease (MD). Study Design: Retrospective case series and literature review. Setting: Tertiary academic medical center. Patients: Patients with clinical diagnosis of unilateral “definite MD.” Intervention: Review of medical records. Main Outcome Measures: Spontaneous nystagmus and the dynamic hVOR gain change at different stages of an acute episode of MD attack. Results: We studied 10 vertigo attacks during the unique stages of the episode. During the acme stage of the attack, lower hVOR gain was recorded on the affected side (mean 0.48 ± 0.23), which was associated with a paralytic nystagmus (beating away from the affected ear). Additionally, the mean hVOR gain remained significantly (p < 0.05) reduced during each of the other stages of the attack as compared with the unaffected side and a control group. After the attack, mean hVOR gains normalized in the affected ear. Mean hVOR gain of the unaffected ear remained normal during all stages. Conclusion: Vestibular function during an attack of MD is a dynamic process associated with fluctuation of the dynamic (hVOR gain) and static (spontaneous nystagmus) processes, which exist in parallel with the perception of vertigo. Our data support vHIT monitoring during an episode to provide objective and accurate evidence of the ear with active disease. This would be particularly useful for those patients with MD presentations of unreliable hearing or assisting to identify the ear to be treated in the case of bilateral MD.