This case aims to report an unusual clinical situation with uncommon and severe side effects, which can even be life threatening for the patient. The ENT and Hematology specialist should be aware of diagnosing and treating adequately.

Benign paroxysmal positional vertigo (BPPV) is one of the most common disorders that causes dizziness. The incidence of horizontal semicircular canal (HSC) BPPV ranges from 5% to 40.5% of the total number of BPPV cases diagnosed. Several studies have focused on establishing methods to treat BPPV caused by the apogeotropic variant of the HSC, namely, the Appiani maneuver (App). In 2016, a new maneuver was proposed: the Zuma e Maia maneuver (ZeM), based on inertia and gravity. The aim of this study is to analyze the efficacy of App versus ZeM in the resolution of episodes of BPPV produced by an affectation of the horizontal semicircular canal with apogeotropic nystagmus (Apo-HSC). A retrospective, quasi-experimental study was conducted. Patients attended in office (November 2014-February 2019) at a third-level hospital and underwent a vestibular otoneurology assessment. Those who were diagnosed with Apo-HSC, treated with App or ZeM, were included. To consider the efficacy of the maneuvers, the presence of symptoms and/or nystagmus at the first follow up was studied. Patients classified as A were those with no symptoms, no nystagmus; A/N+: no symptoms, nystagmus present during supine roll test; S: symptoms present. Previous history of BPPV and/or otic pathology and calcium levels were also compiled. From the 54 patients included, 74% were women. The average age was 69. Mean follow-up: 52.51 days. In those patients without previous history of BPPV (n = 35), the probability of being group A was 63% and 56% (p = 0.687) when treated with App and ZeM, respectively, while being A/N+ was 79% and 87% for App and ZeM (p = 0.508). Of the 19 patients who had previous history of BPPV, 13% and 64% were group A when treated with App and ZeM (p = 0.043), and 25% and 82% were A/N+ after App and ZeM, respectively (p = 0.021). In conclusion, for HSC cupulolithiasis, ZeM is more effective than App in those cases in which there is a history of previous episodes of BPPV (A: 64% (p = 0.043); A/N+: 82% (p = 0.021)).

Purpose To describe the anatomic relationship of the lingual nerve with the lateral oropharyngeal structures. Methods An anatomic dissection of the lateral oropharyngeal wall was conducted in eight sides from four fresh-frozen cadaveric heads. Small titanium clips were placed along the lingual nerve and the most anterior and medial border of the medial pterygoid muscle. Radiological reconstructions were employed for optimal visualization; the coronal view was preferred to resemble the surgical position. The distance between the lingual nerve and the medial pterygoid muscle at its upper and lower portion was measured radiologically. The trajectory angle of the lingual nerve with respect to the pterygomandibular raphe was obtained from the intersection between the vector generated between the clips connecting the upper and lower portion of the medial pterygoid muscle with the vector generated from the lingual nerve clips. Results The mean distance from the upper portion of the medial pterygoid muscle and superior lingual nerve clips was 10.16 +/- 2.18 mm (mean +/- standard deviation), and the lower area of the medial pterygoid muscle to the lingual nerve was separated 5.05 +/- 1.49 mm. The trajectory angle of the lingual nerve concerning to the vector that describes the upper portion of the most anterior and medial border of the medial pterygoid muscle with its lower part was 43.73o +/- 11.29. Conclusions The lingual nerve runs lateral to the lateral oropharyngeal wall, from superiorly-inferiorly and laterally-medially, and it is closer to it at its lower third.