Neurologic Manifestations of Benign Positional Vertigo Treatment & Management

Since benign paroxysmal positional vertigo is benign and can resolve on its own in weeks to months, the argument has been made that simple observation is all that is needed. However, this involves weeks or months of discomfort and vertigo, with the danger of falls and other accidents or injuries that may arise out of the episodic vertigo spells.

Vestibulosuppressant medications usually do not stop the vertigo. In some cases, they may provide minimal relief; however, they do not solve the problem but only mask it. To complicate matters, they may cause grogginess and sleepiness.

Vestibular rehabilitation is a noninvasive therapy that can achieve success after lengthy periods of time. Unfortunately, it causes repeated stimulation of vertigo while performing the therapeutic maneuvers.

Particle repositioning techniques are represented by 2 major variations that developed simultaneously, yet independently, in the United States and France. These variations are the "Epley Method" and the "Semont Method." Both involve movements of the head to rearrange displaced particles. The Semont maneuver involves rapid and vigorous side-to-side head and body movements. The Epley maneuver is more gentle, involving a reclining movement, and is described below. The author favors the Epley maneuver because it seems less violent and more physiologically sensible with respect to the presumed canalithiasis etiology.

Recently, research has been conducted on multiaxial positioning devices that can perform canalith repositioning using 360-degree rotation in the proper plane of the semicircular canals. ^[4] These automated repositioning chairs can help isolate the problematic semicircular canal, and they can help treat that particular canal without tremendous effect on the other canals. Furthermore, patients are securely fastened to the seats; therefore, they can be rotated more easily and can achieve the appropriate repositioning points better.

The canalith repositioning procedure (CRP) is a simple, noninvasive, office treatment that is designed to actually cure benign paroxysmal positional vertigo in 1–2 sessions (see Media files 1-3). ^{[5, 6, 7, 8, 9, 10]} This therapy has enjoyed a success rate greater than 97% for patients with benign paroxysmal positional vertigo. ^{[11, 2]} Computer-controlled CRP is also effective for the treatment of posterior canal BPPV, with a success rate similar to those treated with the Epley maneuver, and is safe and easy to perform on patients. ^[12]

The procedure is conducted as follows:

• Starting position: Patient is sitting, head turned 45 degrees toward the ipsilateral side.

  • The patient begins the procedure in a sitting position. The head is turned toward the affected side.

  • A mastoid bone oscillator is applied and held in position behind the affected ear by a headband to help agitate the particles so that they can move more easily.

• Position 1: Patient is supine, head turned 45 degrees toward the ipsilateral side.

  • The patient is reclined slowly to the supine position of the affected side.

  • The rate is titrated to the point of no nystagmus and no symptoms. This usually takes about 30 seconds.

• Position 2: Patient is supine, 15 degrees Trendelenburg, head turned 45 degrees toward the ipsilateral side.

  • The patient is reclined further to the Dix-Hallpike position of the affected side. This usually takes 10 seconds longer.

  • Another 20 seconds are spent in that Dix-Hallpike position (affected ear down).

• Position 3: Patient is supine, 15 degrees Trendelenburg, head turned 45 degrees toward the contralateral side.

  • The patient's head is turned slowly from position 3 toward the opposite side.

• Position 4: Patient is lying on the side with the contralateral shoulder down, head turned 45 degrees below the horizon toward the contralateral side.

  • The body is rolled so that the shoulders are aligned perpendicular to the floor (ie, affected ear up).

  • The head is turned further so that the nose points 45 degrees below the plane of the horizon. This usually takes another 40 seconds.

• Position 5: Patient is sitting, head turned at least 90-135 degrees toward the contralateral side.

  • The patient is raised back to the sitting position with the head turned away from the affected side.

• Position 6: Finally, the head is turned back to the midline. The mastoid bone oscillator is turned off and the headband is removed.

Dix-Hallpike test is done immediately following the procedure. If nystagmus is seen, the procedure is repeated.

After the procedure, the patient is instructed to avoid agitation of the head for about 48 hours while the particles settle, and to return within a week for follow-up examination.

The steps involved in performing left-sided canalith repositioning procedure (CRP). The head is positioned 30 degrees toward the affected ear (left ear in this example). Next it is brought gently back to a reclining position. Note how the labyrinthine particles gravitate.

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Continuation of the canalith repositioning procedure (CRP). Once supine, the head is rotated 180 degrees (ie, away from the affected side).

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Another view of the canalith repositioning procedure treating the left ear.

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Surgery usually is reserved for those in whom canalith repositioning procedure is not successful. Surgery is not the first line of treatment because it is invasive and carries the possibility of complications (eg, hearing loss, facial nerve damage).

The options, all of which have a high chance of vertigo control, include the following:

• Labyrinthectomy

• Posterior canal occlusion

• Vestibular nerve section

• Singular neurectomy (ie, selective denervation of the posterior semicircular canal, sparing the other parts of the ear)

Of all of these options, the posterior semicircular canal occlusion seems to be gaining the most favor. This procedure has the capability of hearing preservation, without sacrifice of the entire vestibular system. Only the affected posterior semicircular canal (or horizontal semicircular canal) is ablated. The other semicircular canals, as well as the saccule and utricle, are left intact. This procedure is far easier to perform than the singular neurectomy. Ongoing studies are evaluating its effects. Some have reported 95% improvement.

Otolaryngological consultation should be considered for differentiating the associated inner ear disorders.

After treatment, patients are instructed to avoid lying down completely flat for 24–48 hours. Sleeping with the head elevated on a few pillows is recommended.

Avoidance of jarring activities or gymnastic flips is recommended.