Benign Paroxysmal Positional Vertigo (BPPV) is the number-one form of vertigo. The successful treatment of BPPV with simple Repositioning or Liberatory Maneuvers provides patients who suffer from this vestibular disorder with almost immediate relief. Presented here is an overview that provides information and references to allow the clinician to pursue this very worthwhile form of treatment for what is a terribly debilitating and potentially dangerous problem.

This is the second article in a three-part series on Benign Paroxysmal Positional Vertigo (BPPV), and it will provide an overview of the various treatment methods available for managing the patient with BPPV and its different forms. The first article (see August HR, pgs. 38-43,72) explains the anatomy and pathology of BPPV, and provides an overview of BPPV diagnostic procedures.

BPPV is the most common form of vertigo among all age groups; however, it is far more prevalent in the older adult population. The successful treatment of BPPV with simple Repositioning or Liberatory Maneuvers (explained below) provides patients who suffer from debilitating positional vertigo with almost immediate relief. For clinicians who are trained to diagnose and treat BPPV, providing this service offers one of the most satisfying treatment skills in the hearing care field.

History
Although the management of BPPV with Canalith Repositioning and Liberatory Maneuvers has gained much attention over the past decade, there is actually a 50-year history of treatment for positional vertigo. Dating back to the original works of Cawthorne1 and Brandt & Daroff2, patients have been provided with a variety of exercise protocols which were designed to ameliorate their symptoms. These procedures, however, provided only limited success as it was believed that the procedures were actually performed not to reposition or displace debris from the semicircular canals, but rather to extinguish or ameliorate the symptoms through desensitization or habituation. They did not take into consideration the differentiation of the semicircular canal involved nor did they seek to differentiate a cupulolithiasis from a canalithiasis (i.e., the condition of the otolith debris adhering to the cupula versus the debris lying within the long process of the posterior canal, respectively).

It was the work of Semont, Freyess & Vitte3 that began to discuss what has become known as a Liberatory Maneuver. This was followed by publications by Epley4 in 1992, which detailed procedures which later became known as the Epley Maneuver. This was followed one year later by the work of Herdman, Tusa & Zee5, which modified the Maneuver into a one-treatment method with a high degree of success. Most clinicians who are performing Repositioning and Liberatory Maneuvers have modified many of the protocols into a hybrid which has produced successful outcomes for them in their own clinics. Over the past several years, many articles have discussed the variations in these protocols and have reported their outcomes.6,7,8,9 Regardless of the methodology used, it appears that, if the diagnosis differentiating canalithiasis from cupulolithiasis and the appropriate canal involvement has been discerned, then the outcomes of the Maneuvers are highly successful.

Treatment Methods
The primary questions which should be asked are:

  1. Which is the involved ear or is it bilateral?
  2. Which canal is involved?
  3. Is it canalithiasis or cupulolithiasis?

A review of the literature and clinical experience suggests the following:

  1. The majority of patients will experience unilateral BPPV. It has been the author’s experience that patients presenting with a bilateral BPPV often have experienced head trauma as an antecedent to the onset of the positional vertigo.
  2. More than 90% of patients will present with a posterior canal involvement. This is due to the anatomical positioning of the posterior canal below the utricle from which the otolith debris emanates.
  3. More than 90% of patients presenting with BPPV symptoms will present with predominately a canalithiasis type of involvement, where the otolith debris lies within the long process of the posterior canal. (The first in this series of articles provided readers with the anatomical and physiological aspects necessary to differentiate the diagnosis.)

Treating Cupulolithiasis vs. Canalithiasis
Cupulolithiasis may be successfully treated utilizing either the Semont Liberatory Maneuver or any of the variations of Canalith Repositioning Maneuvers. The decision, therefore, on which method to follow becomes a matter of comfort or choice for the clinician. The patient’s biomechanics should also be taken into consideration as the Liberatory Maneuver requires the movement of the patient in mass and may be inappropriate for those patients who are at risk for basilar arterial stroke or have undergone a hip replacement within 90 days of the treatment (see first article in this series). The Canalith Repositioning Maneuver tends to be more comfortable for most patients, as it requires them only to move their head and roll onto their side. There are patients that may have certain physical limitations whether it be orthopedic, neuromuscular or obesity that may make one technique easier and more comfortable for both patient and clinician. The success rate of either procedure is greater than 90%.

According to Schuknechts’ theory10 of cupulolithiasis, the debris is adhering to the cupula rather than free floating in the long process of the posterior canal. This theory, according to Semont’s Liberatory Maneuver8, recognizes that the debris cannot merely be repositioned by rotation of the head, but must use some basic principals of physics to dislodge the debris from the cupula so that it can then be released and allowed to return to the utricle and dissolve. The differentiating factor and the diagnosis is based on whether the symptoms will abate with repetition of a provoking maneuver. For patients with acute BPPV who may also have emesis (vomiting), repetition of three and four Modified Hallpike Maneuvers as part of the diagnostic process may be somewhat severe. The Canalith Repositioning Maneuver4 has therefore become the author’s first method of choice. If the patient then proves to be symptomatic and the debris cannot be cleared, a Liberatory Maneuver to dislodge the otoliths from the cupula is performed.

Treating Bilateral BPPV
Although the incidence of bilateral BPPV is far less common than unilateral BPPV, the clinician will have to decide the sequence of treatment when confronted with bilateral BPPV patients.

It has been the author’s experience that the most practical approach to the treatment of bilateral BPPV patients is to begin with the ear that the patient believes has the most acute symptoms or the side that patient wishes he/she could return to “sleeping on” as quickly as possible. Once an appropriate method of treatment is selected, whether it be Canalith Repositioning or Liberatory Maneuver, the patient is then treated accordingly, provided with written and verbal prohibitions for activities and is scheduled for a return appointment in approximately one week.

At the second follow-up appointment, the patient is reevaluated to ensure that the otolith has been properly cleared from the treated ear and that there has been no migration into the horizontal or anterior canals. The patient is then retested to confirm that the opposite ear, which was not treated, is still symptomatic. That ear is then treated with the appropriate method, and the patient is reinstructed in their prohibitions (covered later in this article) and is asked to return in one week.

At the third visit, the patient is positioned to ensure that the debris is cleared from both ears and there has been no migration into the horizontal or anterior canals of either ear. At that point, the treatment is concluded and there are no further recommendations or prohibitions.

Complications of Treatment
Clinicians participating in the treatment and management of BPPV patients should recognize that there may be several complications which, although uncommon, must be dealt with quickly and efficiently in the event that they occur.

  • Horizontal Canal Migration: The migration of the otolith debris into the horizontal canal has been well reported in the literature.11,12,13 (Author’s Note: For hearing care professionals performing ENGs without the benefit of video-oculographic recordings, this phenomenon can be the explanation for a direction-changing nystagmus seen in positional ENG sub-tests.) Following Canalith Repositioning (or occurring spontaneously), the debris can migrate into the horizontal canal. These patients will present with a burst of linear horizontal nystagmus with its fast phase beating geotropically towards the undermost involved horizontal canal. If the patient’s head is turned onto the opposite or unaffected ear, there is a linear horizontal ageotropic nystagmus beating away from the normal undermost ear towards the effected ear.
         The treatment of choice for patients who present with a horizontal canal migration is a “360-degree barbeque roll” treatment protocol. This protocol rolls the patient in a 360° pattern away from the effected ear. The patient beginning in the supine position is rolled onto their left side (supposing a right horizontal canal BPPV), then maintained in that position until any vertigo or nystagmus subsides. Then they are rolled onto their stomach, again waiting for nystagmus or vertigo to subside. Then they are rolled onto their right side, waiting for symptoms to subside with a return to the initial supine position. The procedure is repeated until the patient is asymptomatic in all positions.
  • Canalith Jam: A rare, but often frightening, occurrence is a canalith jam. This can best be described as an inability of the otolith debris to clear the common crus as the debris falls downward from the posterior canal into the utricle, the final stage of the Canalith Repositioning Maneuver. In the instance of a jam, the patient will become symptomatic and the symptoms will not abate. The sensation of falling or rapidly tumbling can be extremely severe, and the only way to clear this is to reverse the Canalith Repositioning protocol in the order in which it was administered.
         In performing well over 500 Repositioning and Liberatory Maneuvers, the author has only had two patients experience a canalith jam. However, it is imperative for the clinician to quickly identify what is occurring and to be able to reverse the process so that the patient can recover.

Post-Treatment Recommendations
There are a wide variety of reported prohibitions for the patient’s activities, ranging from 24-48 hours following treatment. Many reports have asked that the patient not lie supine or tip their head for 48 hours following treatment. This is often assisted by the wearing of a soft cervical collar. Then for several nights or up to a week following the treatment, the patient is asked to refrain from lying on the treated or effected side when sleeping. In the author’s experience, utilizing a modified prohibition of having the patient only avoid tipping their head or lying supine for 24 hours has proven to be sufficient. This may also be supported by the work of Zucca16, who reported that otolith debris in the vestibular system of frogs would dissolve within the calcium poor endolymph well within the 24-hour period. Recent reports have suggested that it may not be necessary for any prohibition of head movement or activity.17

To Vibrate or Not to Vibrate…

The original work of Epley, as well as Li10, recommend the use of vibration to maximize treatment outcome. However, a review of the literature suggests that most researchers and clinicians have not found the vibrator to be a critical component in the treatment of BPPV. There are also other options which have ranged from bone conduction oscillators, tuning forks or tapping of the mastoid process during the treatment procedure to facilitate movement of the debris. This author has found in treating over 500 patients with both Liberatory and Canalith Repositioning Procedures that the vibration or tapping has not been a critical factor. In those patients who have required more than the average number of treatments, tapping the mastoid process has been somewhat successful in clearing the debris. The only instances of horizontal canal migration during or subsequent to a Canalith Repositioning Maneuver have occurred in those patients who received the tapping. u

Patient Education
The average BPPV patient is seen by numerous physicians and specialists before an accurate diagnosis of BPPV is made. These patients may undergo extensive medical and radiographic studies, costing thousands of dollars to rule out other possible causes of their acute vertigo.18 When the patient is finally diagnosed and the treatment is discussed with them, they may be incredulous that something as simple and easily performed as a Canalith Repositioning is really going to work.

During the past eight years, the American Institute of Balance has developed a number of educational materials, as well as some of the more easily understood article reprints and patient testimonials, so patients and their families may better understand the diagnosis and the treatment recommendations. If the patient does not have a high level of confidence in the treatment method and practitioner, he/she may not be as compliant and results can be negatively affected. Patients are provided with educational materials prior to the treatment. They are encouraged to discuss this with friends, family members or their physician(s). Today’s medical consumer is often quite knowledgeable. For example, it is fairly common for them (or a family member) to "surf the web," confirming the recommended treatment method. With this in mind, it may be advisable to provide them with a variety of websites to validate the recommendations.

Prophylactic Management
This author does not recommend patients perform Cawthorne-Cooksey or Brandt-Darrof maneuvers at home for treatment of BPPV. These methods have been shown not to be efficacious in self treatment compared to clinician repositioning or liberatory treatment. Furthermore, it is unlikely that the acutely vertiginous patient will willingly put themselves into a provocative position and repeat that multiple times. The biomechanics of these "maneuvers" for individuals with neuromuscular or orthopedic involvement is contraindicated.

There may be benefit in providing a modified exercise regimen for patients that have recurrent BPPV, once an underlying medical condition, such as acoustic neuroma, can be categorically ruled out. This author has begun providing his patients with simplified variation of a Canalith Repositioning, which they can perform at home during asymptomatic periods only. The concept is to "empty the wastebasket" before it becomes full and therefore prevent a significant amount of debris to accumulate to cause the patient to once again become symptomatic.

Summary
It is beyond the scope of this overview to present clinicians with a comprehensive or in-depth treatment plan for all the different variations of treatment methods and forms of BPPV. It is the author’s hope that this review will provide information and references to allow the clinician to pursue this very worthwhile form of treatment for what is the most common cause of positional vertigo. The third and final article in this series will review treatment outcomes as well as the impact on quality of life utilizing the SF-36 Questionnaire. The final article is in cooperation with Carl Crandall, PhD, of the Univ. of Florida in Gainesville.

f02a.jpg (4919 bytes)Richard E. Gans, PhD, is founder and exec. dir. of the Amer. Inst. of Balance, Seminole, FL, and author of Vestibular Rehabilitation: Protocols and Programs and the ENG Handbook: A Clinical Guide.

References
1. Cawthorne T: The physiological basis for head exercises. J Chart Soc Physiotherapy 1944; 30: 106-7.

2. Brandt T & Daroff RB: Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol 1980; 106: 484-5.

3. Semont A, Freyss G & Vitte E: Curing the BPPV with a liberatory manœuvre. Adv Otorhino Laryngol 1988; 42: 290-293.

4. Epley JM: The canalith repositioning procedure for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surgery 1992; 107: 399-404.

5. Herdman SJ, Tusa RJ, Zee DS, Proctor LP & Mattox DE: Single treatment approaches to benign paroxysmal positional vertigo. Arch Otolaryngol 1993; 119: 450-454.

6. Coppo CF, Singarelli S, Fracchia P. Benign Paroxysmal Positional Vertigo: Follow up of 165 Cases Treated by Semont’s Liberating Maneuver. Acta Otorhinolaryngol Ital 1996 Dec; 16 (6): 508-512.

7. Wolf JS, Boyev KP & Manokey DE: Success of the Modified Epley Maneuver in treating benign paroxysmal positional vertigo. Laryngoscope 1999 June; 109 (6): 900-903.

8. Fung K & Hall SF: Particle Repositioning Maneuver: Effective treatment for benign paroxysmal positional vertigo. J Otolaryngol 1996 Aug: 25 (4): 243-248.

9. Nunez RA, Cass SP & Furman JM: Short and long term outcomes of canalith repositioning for benign paroxysmal positional vertigo. J Otolaryngol 2000, May: 122 (5): 647-652.

10. Li JC: Mastoid oscillation: A critical factor for success in canalith repositioning procedure. Otolaryngol Head Neck Surg 1995; 112: 670-675.

11. Schuknecht HF. Cupulolithiasis. Arch Orolaryngol 1969; 90: 765-778.

12. Steddin S, Ing D & Brandt T: Horizontal Canal Benign Paroxysmal Positional Vertigo (h-BPPV): Transition of canalithiasis to cupulolithiasis. Ann Neurol 1996; Dec, 40 (6): 918-922.

13. Fife TD, Recognition and Management of Horizontal Canal Benign Positional Vertigo. Amer J Otol 1998 May; 19 (3): 345-351.

14. Vannucchi P, Giannoni B & Pagnini P: Treatment of horizontal semicircular canal benign paroxysmal positional vertigo. J Vestib Res 1997, Jan-Feb; 7 (1): 1-6.

15. Lempert T, Wolsley C, Davies R, Gresty MA & Bronstein AM: Three hundred sixty degree rotation of the posterior semicircular canal for treatment of benign paroxysmal positional vertigo: A placebo-controlled trial. Neurology 1997 Sep; 49 (3): 729-733.

16. Zucca G, Valli S, Valli P, Perin P & Mira E: Why do benign paroxysmal positional vertigo episodes recover spontaneously? J Vestib Res 1998 Jul-Aug; 8 (4): 325-329.

17. Nut D, Nati C & Passali D. Treatment of benign paroxysmal positional vertigo: No need for postmaneuver restrictions. J Otolaryngol 2000 Mar; 122 (3): 440-444.

18. Li JC, Li CJ, Epley JC & Weinberg L. Cost-effective management of benign positional vertigo using canalith repositioning. J Otolaryngol 2000 Mar; 122 (3): 334-339.

Correspondence can be addressed to HR or Richard Gans, PhD, American Institute of Balance, 11290 Park Blvd., Seminole, FL 33772; email: [email protected] ; website: www.dizzy.com .