By Marcello Cherchi, MD PhD
For patients
Benign paroxysmal positional vertigo (BPPV) is an inner ear problem that can cause the symptom of disequilibrium. BPPV can affect different parts of the inner ear. The anterior semicircular canal (also called the superior semicircular canal) is the least commonly affected part of the ear in BPPV. Treatment is usually done by a physical therapist using a specific series of maneuvers.
For clinicians
Anterior (sometimes called superior) semicircular canal benign paroxysmal positional vertigo (BPPV) is the rarest form of BPPV. This rarity is plausibly due to the fact that the anterior semicircular canal is the highest of the three canals, and in the course of regular activities, gravity is likely to cause loose otoliths to exit that higher canal and instead enter one of the lower canals (posterior or lateral). Some literature suggests that anterior semicircular canal BPPV is more common after head trauma (Jackson, Morgan et al. 2007, Dlugaiczyk, Siebert et al. 2011).
Anterior semicircular canal BPPV is diagnosed using the Dix-Hallpike maneuver (like posterior semicircular canal BPPV), but the pattern of observed eye movements is different than that found with posterior semicircular canal BPPV. Specifically, in anterior semicircular canal BPPV the pattern of observed eye movements consists of a combination of nystagmus in which the fast phase is contraversive (beating towards the unaffected ear), contratorsional (the top pole of the eye rotates towards the unaffected ear) and down beat (towards the patient’s feet).
Because anterior semicircular canal BPPV is relatively rare, it has also been more difficult to study. Treatment maneuvers described include the reverse Epley maneuver (Honrubia, Baloh et al. 1999), the Semont maneuver (Semont, Freyss et al. 1988), the Casani maneuver (Casani, Cerchiai et al. 2011), the Kim maneuver (Kim, Shin et al. 2005) and the Yacovino maneuver (Yacovino, Hain et al. 2009).
Given that anterior semicircular canal BPPV is rare, that its pattern of nystagmus is unusual, and that its treatment maneuvers are neither well known nor well demonstrated on internet videos, it is appropriate for patients to consult with a vestibular physical therapist.
References
Casani, A. P., N. Cerchiai, I. Dallan and S. Sellari-Franceschini (2011). “Anterior canal lithiasis: diagnosis and treatment.” Otolaryngol Head Neck Surg 144(3): 412-418.
Dlugaiczyk, J., S. Siebert, D. J. Hecker, C. Brase and B. Schick (2011). “Involvement of the anterior semicircular canal in posttraumatic benign paroxysmal positioning vertigo.” Otol Neurotol 32(8): 1285-1290.
Honrubia, V., R. W. Baloh, M. R. Harris and K. M. Jacobson (1999). “Paroxysmal positional vertigo syndrome.” Am J Otol 20(4): 465-470.
Jackson, L. E., B. Morgan, J. C. Fletcher, Jr. and W. W. Krueger (2007). “Anterior canal benign paroxysmal positional vertigo: an underappreciated entity.” Otol Neurotol 28(2): 218-222.
Kim, Y. K., J. E. Shin and J. W. Chung (2005). “The effect of canalith repositioning for anterior semicircular canal canalithiasis.” ORL J Otorhinolaryngol Relat Spec 67(1): 56-60.
Semont, A., G. Freyss and E. Vitte (1988). “Curing the BPPV with a liberatory maneuver.” Adv Otorhinolaryngol 42: 290-293.
Yacovino, D. A., T. C. Hain and F. Gualtieri (2009). “New therapeutic maneuver for anterior canal benign paroxysmal positional vertigo.” J Neurol 256(11): 1851-1855.
