Complications
Serious complications of canalith repositioning procedure (CRP) are rare.
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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.
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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.
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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 can 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%.
A retrospective study by Picciotti et al indicated that in individuals who have experienced BPPV, the risk of recurrence is higher in female patients, older patients, and patients with comorbidities (particularly psychiatric disorders). The persistence rate was significantly higher in persons with posttraumatic BPPV (45.2%) than in those with nontraumatic BPPV (20.5%). The study included 475 patients, including 139 (29.3%) with recurrence of BPPV. [18]
A retrospective study by Tan et al indicated that patients with hypertension comorbid with BPPV have a greater BPPV recurrence rate than do those with idiopathic BPPV. [19]
Patient Education
For patient education resources, see the Brain and Nervous System Center, as well as Benign Positional Vertigo, Vertigo, and Dizziness.
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The patient is placed in a sitting position with the head turned 45° towards the affected side and then reclined past the supine position.
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The patient is then brought back up to the sitting position.
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Next, the patient is rolled 180° from the affected side to the opposite side. Note that the position of the head is 45° toward the affected side before the roll. The head winds up facing down, 180° away from the starting position.
