eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Vertigo & Dizziness

Benign Paroxysmal Positional Vertigo: Follow-up

Author: John C Li, MD, Private Practice in Otology and Neurotology; Medical Director, Balance Center
Coauthor(s): John Epley, MD, Director, Portland Otologic Clinic
Contributor Information and Disclosures

Updated: Sep 25, 2009

Follow-up

Complications

  • Serious complications of canalith repositioning procedure (CRP) are rare.
    • Nausea/vomiting: This is usually not a problem if the procedure is performed slowly with mastoid oscillation. In severely symptomatic or anxious patients, premedication with diazepam (Valium) or prochlorperazine (Compazine) may be used.
    • Failure: Although rare, failure can occur in approximately 3-15% of patients (depending upon the series). If no effect is observed, the recommendation is to repeat the procedure. If not successful, investigate other diagnoses. Residual BPPV usually means that purging of canalithiasis was not complete; therefore, repeat the procedure.
    • Worse vertigo afterward: In the event of worsened vertigo after CRP, consider differential diagnoses as follows:
      • Canal jam occurs when the bolus of canalithiasis becomes stuck at the relatively narrower distal canal (near the apex area). Patients become vertiginous upon moving between position 5 and position 6. The recommendation is to reverse CRP back to position 3 in an attempt to unjam the canaliths.
      • Symptoms of contralateral BPPV or other forms of BPPV occur when the bolus of canaliths becomes sidetracked into another SCC. Involvement of the SCC mimics BPPV of the contralateral PSC. The topic of other canal involvement and cupulolithiasis treatment cab be quite complex and is beyond the scope of this chapter.
      • Dispersion is possible. Possibly, once shaken, the canaliths are suspended into solution much like dirt in muddy water. As long as they remain suspended, the patient has no symptoms. When the canaliths finally settle, the vertigo can return.

Prognosis

Prognosis following CRP is usually good. Spontaneous remission can occur within 6 weeks, although some cases never remit. Once treated, the recurrence rate is 10-25%.

Patient Education

For excellent patient education resources, visit eMedicine's Brain and Nervous System Center. Also, see eMedicine's patient education articles Benign Positional Vertigo, Vertigo, and Dizziness.

Miscellaneous

Medicolegal Pitfalls

When performing the Dix-Hallpike maneuver or canalith repositioning procedure (CRP), be careful of the patient's spine condition, particularly the condition of the cervical spine. Avoid hyperextension of the neck and violent sudden movements. The authors have been asked to consult on one case in which a Semont maneuver preformed at another institution was allegedly the cause of a vertebral artery dissection.

 


More on Benign Paroxysmal Positional Vertigo

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

  1. Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. Sep-Oct 1980;88(5):599-605. [Medline].

  2. [Guideline] Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, et al. 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. May 27 2008;70(22):2067-74. [Medline].

  3. [Guideline] 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].

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

  5. Fung K, Hall SF. Particle repositioning maneuver: effective treatment for benign paroxysmal positional vertigo. J Otolaryngol. Aug 1996;25(4):243-8. [Medline].

  6. 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].

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

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

  9. Massoud EA, Ireland DJ. Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. J Otolaryngol. Apr 1996;25(2):121-5. [Medline].

  10. Roberts RA. Efficacy of a new treatment maneuver for posterior canal benign paroxysmal positional vertigo.

  11. Roberts RA. Efficacy of a new treatment maneuver for posterior canal benign paroxysmal positional vertigo.

  12. Smouha EE, Roussos C. Atypical forms of paroxysmal positional nystagmus. Ear Nose Throat J. Sep 1995;74(9):649-56. [Medline].

  13. 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].

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Further Reading

Clinical guidelines

Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, Hain TC, Herdman S, Morrow MJ, Gronseth GS, Quality Standards Subcommittee, American Academy of Neurology. 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 2008 May 27;70(22):2067-74. 2

Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, Chalian AA, Desmond AL, Earll JM, Fife TD, Fuller DC, Judge JO, Mann NR, Rosenfeld RM, Schuring LT, Steiner RW, Whitney SL, Haidari J, American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2008 Nov;139(5 Suppl 4):S47-81. 3

Turski PA, Seidenwurm DJ, Davis PC, Brunberg JA, De La Paz RL, Dormont PD, Hackney DB, Jordan JE, Karis JP, Mukherji SK, Wippold FJ II, Zimmerman RD, McDermott MW, Sloan MA, Expert Panel on Neurologic Imaging. Vertigo and hearing loss. [online publication]. Reston (VA): American College of Radiology (ACR); 2006. 8 p.

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Keywords

vertigo, dizziness, benign paroxysmal positional vertigo, vertigo treatment, causes of vertigo, vertigo inner ear, positional vertigo, paroxysmal positional vertigo, benign positional vertigo, vertigo causes, vertigo symptoms, benign, benign vertigo, BPPV, posterior superior semicircular canal, lateral semicircular canal, posterior superior SCC, lateral SCC, canalithiasis, cupulolithiasis, dizziness, nystagmus, Ménière disease, whirling vertigo, vertigo, canalith repositioning procedure, CRP, Dix-Hallpike test, cupulolithiasis theory, canalithiasis theory

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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.

Coauthor(s)

John Epley, MD, Director, Portland Otologic Clinic
John Epley, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and Oregon Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Michael E Hoffer, MD, Director, Spatial Orientation Center, Department of Otolaryngology, Naval Medical Center of San Diego
Michael E Hoffer, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: American biloogical group Royalty Other

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Peter S Roland, MD, Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director of Clinical Center for Auditory, Vestibular and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Adjunct Professor of Communicative Disorders, University of Texas School of Human Development
Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Laryngological Rhinological and Otological Society, American Neurotology Society, American Otological Society, North American Skull Base Society, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Alcon labs Honoraria Speaking and teaching; GSK Honoraria Speaking and teaching; Advanced Bionics Honoraria Board membership; Cochlear corp Honoraria Board membership; Med El corp travel grants Consulting

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

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