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 posterior semicircular canal (also called the inferior semicircular canal) is the most commonly affected part of the ear in BPPV. Treatment is usually done by a physical therapist using a specific series of maneuvers.
For clinicians
Posterior semicircular canal benign paroxysmal positional vertigo (BPPV) is by far the most common type, accounting for over 80% of cases.
Posterior semicircular canal BPPV can be triggered in a variety of positions, some of the more common of which are given epithets in the literature; examples include the “top shelf phenomenon” (when a patient inclines the head backwards while reaching for an object above her head) (Squires, Weidman et al. 2004) and the “under the sink phenomenon” (when an individual leans forward and turns the head horizontally while trying to get the detergent out from under the sink). Other common scenarios include lying on one side, or inclining the head backwards (such as in the dentist’s chair, or at the hairdresser’s).
The diagnosis of posterior semicircular canal BPPV is secured by observing a specific pattern of eye movements when the patient is in a specific position. The diagnostic position is called the Dix-Hallpike maneuver (Dix and Hallpike 1952, Dix and Hallpike 1952, von Brevern, Bertholon et al. 2015). The observed eye movement is a pattern of nystagmus consisting of a combination of nystagmus in which the fast phase of the eye movement is ipsiversive (beating towards the affected ear), ipsitorsional (the top pole of the eye rotates towards the affected ear) and up beat (towards the top of the patient’s head).
In cases where the posterior semicircular canal is involved on only one side, treatment typically begins with the Epley maneuver (or a variant called the canalith repositioning maneuver) on that side (Epley 1980). Multiple trials have established the efficacy of this treatment (Fife, Iverson et al. 2008, Hilton and Pinder 2014, Bhattacharyya, Gubbels et al. 2017). If an appropriate trial of the Epley maneuver fails, then some physical therapists and clinicians will consider other maneuvers, such as the Semont maneuver (Semont, Freyss et al. 1988), the Foster maneuver (Foster, Ponnapan et al. 2012) or the Gans maneuver (Roberts, Gans et al. 2006). The efficacy of these maneuvers has been assessed in meta-analyses (Hilton and Pinder 2014). All of these maneuvers are intended to treat posterior semicircular canal BPPV on one side when that side is known to be affected. Note that one cannot “alternate” treatment sides, because treating a given side will “undo” whatever had been accomplished in treating the opposite side. In other words, if an individual is thought to have posterior semicircular canal BPPV on one side but the side is unknown, one cannot “just try treating both sides.” Or, if an individual is definitely known to have bilateral posterior semicircular canal involvement, one cannot alternate treatment sides.
In cases where the posterior semicircular canal is known to be involved on both sides, treatment sometimes begins with the Brandt-Daroff maneuver (Brandt and Daroff 1980).
References
Bhattacharyya, N., S. P. Gubbels, S. R. Schwartz, J. A. Edlow, H. El-Kashlan, T. Fife, J. M. Holmberg, K. Mahoney, D. B. Hollingsworth, R. Roberts, M. D. Seidman, R. W. Steiner, B. T. Do, C. C. Voelker, R. W. Waguespack and M. D. Corrigan (2017). “Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).” Otolaryngol Head Neck Surg 156(3_suppl): S1-S47.
Brandt, T. and R. B. Daroff (1980). “Physical therapy for benign paroxysmal positional vertigo.” Arch Otolaryngol 106(8): 484-485.
Dix, M. R. and C. S. Hallpike (1952). “The pathology symptomatology and diagnosis of certain common disorders of the vestibular system.” Proc R Soc Med 45(6): 341-354.
Dix, M. R. and C. S. Hallpike (1952). “The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system.” Ann Otol Rhinol Laryngol 61(4): 987-1016.
Epley, J. M. (1980). “New dimensions of benign paroxysmal positional vertigo.” Otolaryngol Head Neck Surg (1979) 88(5): 599-605.
Fife, T. D., D. J. Iverson, T. Lempert, J. M. Furman, R. W. Baloh, R. J. Tusa, T. C. Hain, S. Herdman, M. J. Morrow, G. S. Gronseth and A. A. o. N. Quality Standards Subcommittee (2008). “Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology.” Neurology 70(22): 2067-2074.
Foster, C. A., A. Ponnapan, K. Zaccaro and D. Strong (2012). “A Comparison of Two Home Exercises for Benign Positional Vertigo: Half Somersault versus Epley Maneuver.” Audiology and Neurotology Extra 2(1): 16-23.
Hilton, M. P. and D. K. Pinder (2014). “The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo.” Cochrane Database Syst Rev(12): CD003162.
Roberts, R. A., R. E. Gans and R. L. Montaudo (2006). “Efficacy of a new treatment maneuver for posterior canal benign paroxysmal positional vertigo.” J Am Acad Audiol 17(8): 598-604.
Semont, A., G. Freyss and E. Vitte (1988). “Curing the BPPV with a liberatory maneuver.” Adv Otorhinolaryngol 42: 290-293.
Squires, T. M., M. S. Weidman, T. C. Hain and H. A. Stone (2004). “A mathematical model for top-shelf vertigo: the role of sedimenting otoconia in BPPV.” J Biomech 37(8): 1137-1146.
von Brevern, M., P. Bertholon, T. Brandt, T. Fife, T. Imai, D. Nuti and D. Newman-Toker (2015). “Benign paroxysmal positional vertigo: Diagnostic criteria.” J Vestib Res 25(3-4): 105-117.
