The treatment of patients with vertigo can be frustrating for patient and physician alike. Acute exacerbations are usually treated symptomatically; symptoms can and often do recur. The canalith repositioning procedure is a new treatment for benign paroxysmal positional vertigo (BPPV). This procedure can alleviate the acute symptoms and has a high rate of success in preventing recurrence of vertigo.
An 80-year-old man presented to our clinic with a complaint of dizziness that had endured for several years. He described his symptoms as attacks of dizziness that felt like "the room spinning around in circles." This symptom became worse when he rolled over in bed from the left side to the right side and occasionally when he got up from sitting or lying down. The attacks resolved spontaneously in 20 to 30 seconds with no aftereffects. The patient had a high-frequency hearing loss caused by years of occupational exposure to loud noise. He also had a history of tinnitus related to the hearing loss.
His history showed no chronic medical problems. He took no medications, and a review of systems was unremarkable.
The patient had a slight bufld and was in no apparent distress. His blood pressure was 152/80 mm Hg; his pulse rate was 84 beats per minute and regular, and his temperature was 36.5[degrees]C 97.7[degrees]F). Pupils were equally round and reactive to light. Extraocular movements were normal. Visual fields were intact by confrontation. Fundi were normal. Tympanic membranes were wer visualized and appeared normal. The throat and the oropharynx were moist, and dentition was poor. Neck examination was normal.
The patient had a markedly positive response to the Dix-Hallpike maneuver with his head hanging to the right. A marked rotatory nystagmus, directed to the right ear, developed after a five-second latency period and was associated with recurrence of the dizziness. The nystagmus lasted approximately 20 seconds and then resolved. Dizziness recurred when the patient sat up. The dizziness and nystagmus were reproducible. The rest of the examination, including gait, cranial nerves, deep tendon reflexes, sensory systems and strength, was normal.
The patient was put through eight cycles of the canalith repositioning procedure and was totally asymptomatic in all positions during the eighth trial. The patient was instructed to wear a soft cervical collar for 48 hours and to return if the dizziness recunx,d. The total time for the repogitioriing procedure was approxirnately 30 minutes.
Diagnosis of BPPV
The procedure known as the Dix-Hallpike maneuver is the classic test for BPPV. In this test, the patient is rapidly moved from a sitting position to a supine position with his or her head hanging approximately 45 percent below horizontal and turned to the right, left or midline. The examiner supports the patient's head at all times. The occurrence of nystagmus and other symptoms is recorded. If the vertiginous symptoms are not elicited on the first attempt, the procedure is repeated with the head turned toward the opposite direction.
The nystagmus that classically accompanies BPPV is characterized by the following: (1) it is elicited in a critical provocative position with a particular ear down; (2) it is predominantly rotatory, with the fast phase toward the lower ear; (3) there is usually a brief one- to five-second latency period between the time the head position is assumed and the time the nystagmus begins; (4) the nystagmus is transient, usually lasting less than 20 seconds; (5) the nystagmus reverses when the head is returned to an upright position, and (6) the severity of the attack response is lessened or the response may fail to appear if the provocative position is repeated two or more times within a short time.
The Canalith Repositioning Procedure
Numerous theories have attempted to explain the cause of BPPV. A recent theory postulates the presence of free-moving densities (basophilic deposits of particulate matter) in the endolymph of the posterior semicircular canal. This condition has come to be called canalithiasis (or canalolithiasis). The symptoms (dizziness and nausea) and nystagmus of BPPV may be explained by the presence of hydrodynamic drag in the endolymph of the posterior semicircular canal. This theory has led to the development of a unique series of head movements to treat BPPV, called the canalith repositioning prosedure.[3,4]
The canalith repositioning procedures for posterior and horizontal canalihthiasis are diagrammed in Figures 1 and 2, respectively. A series of sequential head positions, designed to reposition the free-moving densities through the semicircular canal system into the utricle, are employed. Timing of the various head positions depends on direct observation of the induced nystagmus. A head position is maintained until nystagmus and vertigo have stopped, at which time the head is moved to the next position. The use of a handheld vibrator applied to the mastoid process of the pathologic ear throughout the movements has been advocated, as a method of improving the results of the canalith repositioning procedure.
It has been estimated that 20 percent 6f "dizzy" patients seen in clinics have BPPV. The canalith repositioning procedure has been shown to be a safe and effective treatment for BPPV. In one prospective study, it was found that 84 percent of patients were either cured or significantly improved after being treated with the canalith repositioning procedure. In a retrospective review of patients treated with the canalith repositioning procedure at another institution, it was found that 100 percent of patients obtained resolution of the nystagmus and positional vertigo; 30 percent experienced one or more recurrences but responded favorably to retreatment, and 10 percent continued to have atypical symptoms, suggesting another pathology. Although the number of patients in these studies was not large (27 patients and 30 patients, respectively), the successes cannot be dismissed. At our institution, the success rate (defined as resolution or improvement of symptoms) has been approximately 89 percent with this method. The canalith repositioning procedure offers the physician a chance not only to alleviate the patient's symptoms without medication, but also to cure a dizziness" problem that can be lifelong.
Figure 1 adapted from Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399-404. Used with permission. Figure 2 adapted from Epley IM. Positional vertigo related to semicircular canalithiasis. Otolaryngol Head Neck Surg 1995;112:154-61. Used with permission.
[Figures 1 to 2 ILLUSTRATION OMITTED]
RELATED ARTICLE: What to Do About Benign Paroxysmal Positional Vertigo
What is benign paroxysmal positional vertigo?
Benign paroxysmal positional vertigo, also called BPPV, is an inner ear problem that causes you to suddenly feel dizzy when you move your head in a certain direction or roll over in bed. You might feel like the room is spinning around in circles. You might feel nausea at the same time. The nausea and dizziness go away in a few seconds. BPPV is bothersome, but it won't hurt you.
What causes BPPV?
BPPV may be caused by a blockage of fluid in the balance centers in your inner ears. The blockage might be made of tiny stones.'
How is BPPV treated?
You should see your doctor if you feel dizzy. Several tests can help your doctor tell if your dizziness is caused by BPPV.
If BPPV is the cause of your symptoms, your doctor can show you some easy head movements that move the stones causing the blockage. The movements of your head can stop the symptoms and may keep the dizziness from coming back. You may also be given medicine to treat the nausea and dizziness.
This information provides a general overview on benign paroxysmal positional vertigo and may not apply to everyone. Talk to your family doctor to find out if this information applies to you and to get more information on this subject.
[1.] Epley JM. BPPV diagnosis and management. Vestibular Update 1992;8:1-4. [2.] Epley JM. Positional vertigo related to semicircular canalithiasis. Otolaryngol Head Neck Surg 1995; 112:154-61. [3.] Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399-404. [4.] Welling DB, Barnes DE. Particle repositioning maneuver for benign paroxysmal positional vertigo. Laryngoscope 1994;104(8 Pt 1):946-9. [5.] Cevette W, Heidlauf K, Smith G, Brey RH, Lynn SG, Pool AC, et al. Success of modified Epley maneuver in benign paroxysmal positional vertigo [Abstract]. ASHA 1993;35:167.
MATTHEW E. BERNARD, M.D. is a senior associate consultant in the Department of Family Medicine at the Mayo Clinic and Foundation, Rochester, Minn., and associate professor in the Mayo Medical School. He graduated from the University of Minnesota Medical School--Minneapolis.
TIMOTHY C. BACHENBERG, M.D. has a private practice in Broken Bow, Nebr. He graduated from the Mayo Medical School, Rochester, Minn.
ROBERT H. BREY, PH.D. is an audiologist at the Mayo Clinic and Foundation, director of the Vestibular Balance Laboratory and a professor of audiology in the Mayo Medical School. He earned an M.A. in audiology from the University of Utah, Salt Lake City. He completed a Ph.D. in audiology at Wayne State University School of Medicine, Detroit, Mich.
Address correspondence to Matthew E. Bernard, M.D., Department of Family Medicine, Akyo Clinic, 200 First St. S. K, Rochester, MN 55905.
COPYRIGHT 1996 American Academy of Family Physicians
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