What is Tumarkin's otolithic crisis (Benign paroxysmal positional vertigo, BPPV)?

From the Guidelines

Tumarkin's otolithic crisis, also known as Benign Paroxysmal Positional Vertigo (BPPV), is a condition characterized by brief, intense episodes of vertigo triggered by specific head movements, diagnosed using the Dix-Hallpike maneuver and treated with canalith repositioning procedures or observation. The diagnosis of BPPV involves identifying vertigo associated with torsional, upbeating nystagmus provoked by the Dix-Hallpike maneuver, as outlined in the clinical practice guideline update 1.

Key Diagnostic Features

• Vertigo associated with torsional, upbeating nystagmus
• Provoked by the Dix-Hallpike maneuver
• Diagnosis of posterior semicircular canal BPPV when the above criteria are met
• Supine roll test to assess for lateral semicircular canal BPPV if the Dix-Hallpike test exhibits horizontal or no nystagmus 1

Treatment Options

• Canalith repositioning procedure for patients with posterior canal BPPV
• Observation with follow-up as initial management for patients with BPPV
• Vestibular rehabilitation therapy to improve balance and reduce fall risk
• Education on the impact of BPPV on safety, potential for disease recurrence, and importance of follow-up 1

Important Considerations

• Differentiating BPPV from other causes of imbalance, dizziness, and vertigo
• Assessing patients for factors that modify management, such as impaired mobility or balance, central nervous system disorders, and increased risk for falling
• Avoiding routine use of vestibular suppressant medications like antihistamines and benzodiazepines 1

From the Research

Definition and Characteristics

• Tumarkin's otolithic crisis (TOC), also known as vestibular drop attacks, is a rare phenomenon characterized by a sudden drop attack without accompanying loss of consciousness, vertigo, or autonomic signs 2.
• It is thought to be of peripheral origin and associated with late-stage Meniere's disease 2.
• TOC is often described as a sudden fall without warning, occurring in patients with Meniere's disease, typically in a flurry during a period of 1 year or less 3.

Prevalence and Correlates

• The frequency of TOC in Meniere's disease varies from 3 to 19% in hospital-based studies, and up to 50-72% in studies with a less restrictive definition of vestibular drop attacks 4.
• TOC is more common in severe and advanced Meniere's disease, and is also associated with co-morbidity with migraine 4.
• The prevalence of TOC in Meniere's disease can occur even in mild cases, and may be complicated by syncope 4.

Clinical Manifestation and Treatment

• TOC is characterized by a sudden drop attack, often without warning, and can be distinguished from drop attacks due to cardiovascular abnormalities, seizure disorders, and other conditions 5.
• The treatment of choice for TOC is either surgical ablation (labyrinthectomy) in the absence of serviceable hearing, or middle fossa vestibular nerve section to preserve serviceable hearing 5.
• Vestibular neurotomy (VN) is also an effective treatment for disabling Meniere's disease and TOC, with a high success rate and low complication rate 6.