Chart 1.

Papers discussing BPPV without nystagmus, published between 2001 and 2009.

Author/Rev./Year	Study Type	Series	Results	Considerations and comments
Tirelli et al.18/Laryngoscope/ 2001	Clinical prospective	43 patients with BPPV without nystagmus, 24 (53.5%) with vertigo, 3 (7%) with nausea, 10 (23.2%) with vertigo and nausea in the positional tests (Dix- Hallpike and Sémont with Frenzel goggles). They were treated by the modified PSCC (posterior semicircular canal) repositioning maneuver. The reassessment was carried out after 5 days.	Complete recovery: 26 (60.46%) patients; 14 (32.56%) partial recovery and 3 (6.9%) did not perceive changes in the symptoms. None of the patients perceive a worsening in their condition. All the 17 (39.46%) patients who did not experience symptom remission were submitted to a new diagnostic investigation, obtaining diagnostics which were different from BPPV.	The maneuver is of low cost and it is not inconvenient to the patient. In the case of treatment failure, new tests were carried out with the goal of looking for other causes for vertigo, excluding BPPV.
Haynes, DS et al./Laryngoscope/ 2002,19	Clinical Prospective Comparative	127(78.4%) patients with BPPV and nystagmus and 35(21.6%) with BPPV without nystagmus, detected in the Dix-Hallpike maneuver without the Frenzel goggles, were submitted to the Sémont treatment maneuver, and reassessed 3 weeks later.	97(76%) patients with BPPV and nystagmus had complete symptom remission, 19 (15%) patients reported improvement. Among the patients with BPPV without nystagmus, symptom remission happened to 22 (63%) patients and 8 (23%) reported improvements. There were not statistically significant differences in the treatment of BPPV with and without nystagmus	The Sémont maneuver proved efficient both in BPPV with nystagmus as in that without nystagmus, with a 13% difference in symptoms improvement. It is a low cost procedure, usually well tolerated by patients.
Ganança MM/ Acta AWHO/2002,25	Paper not found, apud Koga et al.26 (2004)
Koga et al.26 / Rev. CEFAC/2004	Cross-sectional Descriptive Observationa	l167 patients with vertigo and/ or dizziness were assessed by means of vector-electronystagmography and the Dix Hallpike test with the Frenzel goggles, with the goal of checking the prevalence of dizziness and/or vertigo associated with head movement and the main alterations found in the vestibular test.	Of the 167 patients, 68 (40.8%). Complained of dizziness and/ or vertigo associated with a change in head position, which was characterized as BPPV, even in the absence of nystagmus. Only 7 (10.3%) had positional or positioning nystagmus visible with the Frenzel goggles.	The authors characterized BPPV without nystagmus in the Dix Hallpike test using the Frenzel goggles, in patients with dizziness and/or vertigo in this positioning.
Ganança MM et al.27/ Acta ORL/ 2005	Review paper	The goal of this paper was to present a review of the main diagnostic and treatment aspects associated with BPPV. It reinforces the use of Frenzel goggles (of 20 dioptries) or the videonystagmography to study nystagmus type and direction, which according to the authors is difficult upon simple observation.	They assessed 17 papers published between 1990 and 2002.	They considered BPPV in the presence of vertigo without nystagmus detected in the Dix Hallpike test and stated that nystagmus was present in 50% of the cases. This lack of nystagmus is attributed to habituation because of regular daily head movements. They report that the BPPV treatment in the absence of nystagmus is not different from the treatment with nystagmus, identifying the labyrinth involved by means of vertigo upon change in head position.
Zhonghua et al.24/ Paper published in Chinese/2007/Abstract in English.	Comparative retrospective clinical analysis	The goal was to assess the clinical and therapeutic characteristics of BPPV comparing BPPV without nystagmus (12 patients) with BPPV with nystagmus (24 patients). BPPV was characterized by the Dix-Hallpike test.	Complete symptom remission was noticed in 11(97.1%) patients with BPPV without nystagmus and in 19(79.2%) patients with nystagmus. Treatment was carried out by the use of a repositioning maneuver (not specified in the paper's abstract).	Original paper in Chinese. BPPV treatment was better in patients without nystagmus when compared to those with it. In the abstract there is no reference as to the use of Frenzel goggles.802
Anagnostou E et al.28/Original paper in German/HNO 3/2007	Retrospective clinical analysis	70 patients complaining of dizziness were analyzed. Of these, 37 (54.1%) had a typical history of BPPV with nystagmus and 33 (48.6%) had typical history without nystagmus which was confirmed by the Dix-Hallpike test and the lateralization maneuver.	Thirty seven (54.1%) patients had a typical history with nystagmus, 30 (83%) were treated with Epley and 7 (17%) with Sémont, becoming symptom-free. Thirty three (48.6%) had typical history without nystagmus and were treated with Brandt-Daroff exercises; 50 % of them did the exercises at home and had complete symptom remission.	The patients were contacted by phone one year after treatment, at the time the retrospective study was being carried out, and questions were made by means of a structured questionnaire. They noticed that even with a normal neurotological exam, a typical medical history of BPPV, even without overt nystagmus upon positioning, diagnosis and treatment can be carried out, avoiding unnecessary complementary tests.
Johkura K; Momoo, T; Kuroiwa, Y29/ J Neurosurg Psychiatry/ 2008	Comparative Clinical Prospective	155 patients complaining of dizziness were part of the control group and 200 patients complaining of chronic dizziness (not accompanied by hearing loss, tinnitus and changes in the MRI), were assessed by means of a camera with infra-red lighting with the Frenzel goggles and video-oculography (the diagnostic test was not specified).	A subtle nystagmus matching that of horizontal semicircular canal BPPV was seen in 98 of the 200 patients with chronic dizziness and in 155 patients without complaints of dizziness. The typical history of BPPV was present in 69 (34.5%) of the patients complaining of dizziness, and in 18 (11.6%) in the control group. The patients with HSCC BPPV (49), detected by means of the medical history and the presence of nystagmus were treated by Brandt-Daroff home exercises for one year. There was a trend towards better symptom remission (p=0.0529) among the 49 (24.5%) patients who underwent the exercises when compared to the 77(13%) who did not do it.	The precise mechanism behind the subtle nystagmus persistence and the BPPV chronicity are unknown. HSCC BPPV seems to be a relatively common cause of dizziness in the elderly. There was no report on the one year follow up of the patients submitted to the Brandt-Daroff exercises.
Munaro G &Silveira AF23/Rev. CEFAC/ 2009	Observational Comparative Cross-sectional	86 patients with clinical history of BPPV who were assessed by means of the positioning tests (Dix-Hallpike and the roll maneuver) and vector-electronystagmography.	45 (49.45%) had nystagmus and 41 (45.04%) did not have it. The complaint of vertigo was common in both groups. Disease duration and the occurrence of associated diseases were divergent, being higher in patients with BPPV without nystagmus.	BPPV without nystagmus was called atypical and with nystagmus was considered typical.
Caldas et al. Rev Bras Otorrinol.; 2009,30	Retrospective Series	They analyzed the charts from 1271 consecutive patients examined in the past 6 years with BPPV by means of the Dix-Hallpike maneuver and the Frenzel goggles.	BPPV had prevalence in the age range between 41 and 60 years. 473 (42.2%), females 798 (62.8%), nystagmus and positioning vertigo in 1033 (81.3%). Cure or improvement by means of the particle repositioning maneuver (77.9%); and the possibility of recurrence (21.8%, in one year of follow up). BPPV with vertigo and without positioning nystagmus happened in 238 patients (18.7%).	As far as clinical evolution is concerned, 990 (77.9%) patients became asymptomatic or improved after the first treatment done by means of the repositioning maneuver. There was no specification as to nystagmus absence or presence as well as the type of repositioning maneuver used. The patients were followed up by one year, without a description of how this process was executed with the treated patients, BPPV recurrence was found in 277 (21.8%) cases; however, the paper is not specific as to their clinical presentation. Four patients (3.2%) maintained symptomatic and there was no characterization of the nystagmus presence or absence in this situation.