BENIGN PAROXYSMAL POSITIONAL VERTIGO - Mydoctor.ca

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BPPV -- BENIGN PAROXYSMAL POSITIONAL VERTIGO10/02/2005 01:37 PManterior and posterior canal. Should debris be present in the common cruse, one would expect a purelytorsional nystagmus. During the down phase of the Dix-Hallpike, when debris is falling backwards towardsthe ampulla, the torsional nystagmus should beat away from the bad ear. During the up phase of the Dix-Hallpike, when debris is moving towards the vestibule, the torsional nystagmus should beat towards the badear.In our clinic setting in Chicago, we have had the most success in treating anterior canal BPPV with a "deepDix-Hallpike". The idea is to invert the anterior canal, allow debris to fall to the "top" of the canal, and thenallow it to further migrate into the common crus and then vestibule.Cupulolithiasis is a condition in which debris is stuck to the cupula of a semicircular canal, rather thanbeing loose within the canal. Cupulolithiasis is not a treatment complication, but rather is part of thespectrum of BPPV. The mechanistic hypothesis is based on pathological findings of deposits on the cupulamade by Schuknecht and Ruby in three patients who had BPPV during their lives (Schuknecht 1969;Schuknecht et al. 1973). Moriarty and colleagues found similar deposits in 28% of 566 temporal bones(Moriarty et al. 1992). Schuknecht pointed out that cupulolithiasis hypothesis fails to explain the usualcharacteristic latency and burst pattern of BPPV nystagmus as well as remissions (Schuknecht et al. 1973).Rather, cupulolithiasis should result in a constant nystagmus. This pattern is sometimes seen (Smouha et al.1995). Cupulolithiasis might theoretically occur in any canal -- horizontal, anterior or vertical, each ofwhich might have it's own pattern of positional nystagmus. Some authors hold that both the cupulolithiasisand canalithiasis hypotheses may be correct (Brandt et al. 1994). If cupulolithiasis is suspected, it seemslogical to treat with either the Epley with vibration, or alternatively, use the Semont maneuver. There are nostudies of cupulolithiasis to indicate which strategy is the most effective.Vestibulolithiasis is a hypothetical condition in which debris is present on the vestibule-side of the cupula,rather than being on the canal side. For this theory, there is loose debris, close to but unattached to thecupula of the posterior canal, possibly in the vestibule or short arm of the semicircular canal. Pathologicstudies of BPPV have found roughly equal amounts of fixed debris on either side of the cupula (Moriarty etal. 1992), suggesting that loose debris might also be found on either side. For the vestibulolithiasismechanism, when the head is moved, stones or other debris might shift from vestibule to ampulla, or withinthe ampulla, impacting the cupula. This mechanism would be expected to resemble cupulolithiasis, having apersistent nystagmus, but with intermittency because the debris is movable. Very little data is available as tothe frequency of this pattern, and no data is available regarding treatment.Multicanal patterns. If debris can get into one canal, why shouldn't it be able to get into more than one ? Itis common to find small amounts of horizontal nystagmus or contralateral downbeating nystagmus in aperson with classic posterior canal BPPV. While other explanations are possible, the most likely one is thatthere is debris in multiple canals. Gradually a literature is developing about these situations (Bertholon et al,2005).WHERE ARE BPPV EVALUATIONS AND TREATMENTSDONE?The Vestibular Disorders Association (VEDA) maintains a large and comprehensive list of doctors whohave indicated a proficiency in treating BPPV. Please contact them to find a local treating doctor.http://www.dizziness-and-balance.com/disorders/bppv/bppv.htmlPage 10 of 13
BPPV -- BENIGN PAROXYSMAL POSITIONAL VERTIGO10/02/2005 01:37 PMAcknowledgementsMORE INFORMATIONLiterature-VEDA has recently published a patient-oriented book on BPPV.Supplemental material is available on the site CD:REFERENCES CONCERNING BPPV:Click here for recent, but possibly less relevant references.See also the following web pageshttp://www.charite.de/ch/neuro/vertigo.html -- This is a self-treatment Epley protocol.Search this sitePublished literature referred to above:Amin M, Giradi M, Neill M, Hughes LF, Konrad H. Effects of exercise on prevention of recurrenceof BPPV symptoms. ARO abstracts, 1999, #774Angeli, S. I., R. Hawley, et al. (2003). "Systematic approach to benign paroxysmal positional vertigoin the elderly." Otolaryngol Head Neck Surg 128(5): 719-25.ATACAN E, Sennaroglu L, Genc A, Kaya S. Benign paroxysmal positional vertigo afterstapedectomy. Laryngoscope 2001; 111: 1257-9.Bertholon, P., A. M. Bronstein, et al. (2002). "Positional down beating nystagmus in 50 patients:cerebellar disorders and possible anterior semicircular canalithiasis." J Neurol Neurosurg Psychiatry72(3): 366-72.BERTHOLON P, Chelikh L, Tringali S, Timoshenko A, et al. Combined horizontal and posteriorcanal benign paroxysmal positional vertigo in three patients with head trauma.Ann Otol Rhinol Laryngol 2005;114:105-10.Black FO, Pesznecker SC, Homer L, Stallings V. Benign paroxysmal positional nystagmus inhospitalized subjects receiving ototoxic medications. Otol Neurotol 2004: 25(3);353-8Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol1980 Aug;106(8):484-485.Brandt T, Steddin S, Daroff RB. Therapy for benign paroxysmal positioning vertigo, revisited.Neurology 1994 May;44(5):796-800.Buckingham RA. Anatomical and theoretical observations on otolith repositioning for benignparoxysmal positional vertigo. Laryngoscope 109:717-722, 1999Cohen, H. S., et al. (1999). "Efficacy of treatments for posterior canal benign paroxysmal positionalvertigo." Laryngoscope 109(4): 584-90.Cohen, H. S., et al. (2004). "Treatment variations on the Epley maneuver for benign paroxysmalpositional vertigo." Am J Otolaryngol 25(1): 33-7.Epley JM. The canalith repositioning procedure: For treatment of benign paroxysmal positionalhttp://www.dizziness-and-balance.com/disorders/bppv/bppv.htmlPage 11 of 13
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