eMedicine Specialties > Neurology > Neuro-otology

Benign Positional Vertigo: Follow-up

Author: John C Li, MD, Private Practice in Otology and Neurotology; Medical Director, Balance Center
Contributor Information and Disclosures

Updated: Apr 27, 2009

Follow-up

Further Inpatient Care

  • Inpatient care usually is not required.
  • Severe cases may require supportive therapy for nausea and vomiting.

Complications

  • Complications of canalith repositioning procedure are rare.
    • Nausea/vomiting: Usually, this is not a problem if the procedure is done slowly with mastoid oscillation. In severely symptomatic or anxious patients, premedication with diazepam (Valium) or prochlorperazine (Compazine) may be used.
    • Failure: Although rare, failure is seen in about 3-5% of all patients.
    • No effect: Repeating the procedure is recommended. If it is not successful, other diagnostic possibilities should be considered.
    • Residual benign paroxysmal positional vertigo: This usually indicates that purging of canalithiasis is not complete, so the procedure should be repeated.
  • If vertigo is worse after canalith repositioning procedure, the differential diagnosis is as follows:
    • Canal jam: This occurs when the bolus of canalithiasis gets stuck at the relatively narrower distal canal (near the apex area). Patients experience vertigo when moving between position 5 and position 6. Reversing canalith repositioning procedure back to position 3 is recommended. This attempts to dislodge the canaliths.
    • Symptoms of contralateral benign paroxysmal positional vertigo or other forms of benign paroxysmal positional vertigo: This occurs when the bolus of canaliths gets sidetracked into another semicircular canal. Involvement of the semicircular canal mimics benign paroxysmal positional vertigo of the contralateral posterior semicircular canal.
    • Cupulolithiasis: The loose canal particles get stuck on the cupula and cause a paradoxical nystagmus profile. This type of nystagmus does not fatigue easily, and can beat in the opposite direction. These particles have to be shaken loose, converted back to canal particles, and then repositioned properly.
    • Dispersion: Once shaken, canaliths conceivably are suspended into solution much like dirt in muddy water. As long as they remain suspended, the patients have no symptoms. When they finally settle, the vertigo can return.

Prognosis

  • Prognosis is usually good.
  • Spontaneous remission can occur within 6 weeks, although some cases never remit.
  • Once treated, benign paroxysmal positional vertigo recurrence rate is between 5% and 15%.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • When performing the Dix-Hallpike test or canalith repositioning procedure, protect the spine (particularly the cervical spine). Avoid hyperextension of the neck and sudden violent movements.
  • The authors were consulted in at least one case in which a Semont maneuver performed elsewhere was allegedly the cause of a vertebral artery dissection.
  • Another issue is the socioeconomic impact of the misdiagnosis of benign positional vertigo. When the diagnosis is not recognized, numerous extraneous tests, including expensive MRIs, blood tests, and ECGs, are often performed. Additional consultations are obtained for opinions from multiple specialists. In one study, patients referred for treatment of benign positional vertigo had an average medical expense bill of $2,684.74 and had 4 physician visits prior to being successfully treated with canalith repositioning.10 Now that benign positional vertigo is becoming more readily recognized and treated by primary physicians, as well as specialists, that average expense bill likely will drop.
 


More on Benign Positional Vertigo

Overview: Benign Positional Vertigo
Differential Diagnoses & Workup: Benign Positional Vertigo
Treatment & Medication: Benign Positional Vertigo
Follow-up: Benign Positional Vertigo
Multimedia: Benign Positional Vertigo
References
Further Reading
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References

  1. Boniver R. Benign paroxysmal positional vertigo: an overview. Int Tinnitus J. 2008;14(2):159-67. [Medline].

  2. Epley JM. The canalith repositioning procedure for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992;107(3):399-404. [Medline].

  3. Parnes LS, McClure JA. Posterior semicircular canal occlusion in the normal hearing ear. Otolaryngol Head Neck Surg. Jan 1991;104(1):52-7. [Medline].

  4. Li JC, Epley J. The 360-degree maneuver for treatment of benign positional vertigo. Otol Neurotol. Jan 2006;27(1):71-7. [Medline].

  5. Weider DJ, Ryder CJ, Stram JR. Benign paroxysmal positional vertigo: analysis of 44 cases treated by the canalith repositioning procedure of Epley. Am J Otol. May 1994;15(3):321-6. [Medline].

  6. Roberts RA, Gans RE, DeBoodt JL, Lister JJ. Treatment of benign paroxysmal positional vertigo: necessity of postmaneuver patient restrictions. J Am Acad Audiol. Jun 2005;16(6):357-66. [Medline].

  7. Prokopakis EP, Chimona T, Tsagournisakis M, et al. Benign paroxysmal positional vertigo: 10-year experience in treating 592 patients with canalith repositioning procedure. Laryngoscope. Sep 2005;115(9):1667-71. [Medline].

  8. Lynn S, Pool A, Rose D, et al. Randomized trial of the canalith repositioning procedure. Otolaryngol Head Neck Surg. Dec 1995;113(6):712-20. [Medline].

  9. Li JC. Mastoid oscillation: a critical factor for success in canalith repositioning procedure. Otolaryngol Head Neck Surg. Jun 1995;112(6):670-5. [Medline].

  10. Li JC, Li CJ, Epley J, Weinberg L. Cost-effective management of benign positional vertigo using canalith repositioning. Otolaryngol Head Neck Surg. Mar 2000;122(3):334-9. [Medline].

  11. Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. Nov 2008;139(5 Suppl 4):S47-81. [Medline].

  12. Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1980;88:599-605. [Medline].

  13. Herdman SJ, Tusa RJ, Zee DS, et al. Single treatment approaches to benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg. Apr 1993;119(4):450-4. [Medline].

  14. Schuknecht HF. Cupulolithiasis. Arch Otolaryngol. Dec 1969;90(6):765-78. [Medline].

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Keywords

benign paroxysmal positional vertigo, benign positional vertigo treatment, benign positional vertigo symptoms, BPV, BPPV, canalithiasis, canalith repositioning procedure, positional vertigo, benign positional vertigo, canalithiasis, cupulolithiasis, vertigo, inner ear disease, Ménière disease, nystagmus

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Contributor Information and Disclosures

Author

John C Li, MD, Private Practice in Otology and Neurotology; Medical Director, Balance Center
John C Li, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Tinnitus Association, Florida Medical Association, and North American Skull Base Society
Disclosure: Nothing to disclose.

Medical Editor

Spiros Manolidis, MD, Associate Professor of Otolaryngology and Neurological Surgery, Columbia University
Spiros Manolidis, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Head and Neck Society, American Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, Society of University Otolaryngologists-Head and Neck Surgeons, and Texas Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Florian P Thomas, MD, MA, PhD, Drmed, Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University
Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Paraplegia Society, and National Multiple Sclerosis Society
Disclosure: Nothing to disclose.

CME Editor

Matthew J Baker, MD, Consulting Staff, Collier Neurologic Specialists, Naples Community Hospital
Matthew J Baker, MD is a member of the following medical societies: American Academy of Neurology
Disclosure: Nothing to disclose.

Chief Editor

Robert A Egan, MD, Director of Neuro-Ophthalmology, St Helena Hospital
Robert A Egan, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, North American Neuro-Ophthalmology Society, and Oregon Medical Association
Disclosure: Nothing to disclose.

 
 
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