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Alashram AR. Semont maneuver for posterior canal benign paroxysmal positional vertigo: a systematic review of randomized controlled trials. Eur Arch Otorhinolaryngol 2024; 281:3985-3999. [PMID: 38530461 DOI: 10.1007/s00405-024-08586-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 02/27/2024] [Indexed: 03/28/2024]
Abstract
PURPOSE This review aimed to examine the effects of the Semont maneuver on posterior canal benign paroxysmal positional vertigo (BPPV). METHODS PubMed, PEDro, SCOPUS, REHABDATA, EMBASE, and Web of Science were searched comprehensively from inception to January 2024. The Physiotherapy Evidence Database (PEDro) scale was employed to evaluate the quality of the selected studies. RESULTS In total, 18 randomized controlled trials met the eligibility criteria. A total of 2237 participants with BPPV (mean age = 58.10 years) were included in this review. Among them, 37.5% were males, and 58% presented with right-sided BPPV. The included studies ranked from 5 to 9 out of 10 (Median = 7), suggesting good to excellent quality on the PEDro scale. The available literature revealed that the Semont maneuver is effective in improving posterior canal BPPV symptoms. CONCLUSION The Semont maneuver is considered a standard option for treating posterior canal BPPV, with a high success rate of around 80%. It is suggested as the primary option for managing posterior canal BPPV in individuals who complain of cervical or lumbar problems, severe cardiac or respiratory conditions. Further studies are strongly needed to understand the long-term effects of the Semont maneuver and to identify the recurrence rate.
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Affiliation(s)
- Anas R Alashram
- Department of Physiotherapy, Middle East University, Airport Road 1666, Amman, Jordan.
- Applied Science Research Center, Applied Science Private University, Amman, Jordan.
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University, Rome, Italy.
- Centre of SpaceBio-Medicine, Department of Systems Medicine, Faculty of Medicine and Surgery, University of Rome "Tor Vergata", 00133, Rome, Italy.
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Vats AK, Vats S, Kothari S, Khamesra R. Concurrent Right Horizontal Semicircular Canalolithiasis and Right Posterior Cupulolithiasis Verses Canal Switch: A Diagnostic Otoneurologic Conundrum. Ann Indian Acad Neurol 2024; 27:84-85. [PMID: 38495225 PMCID: PMC10941911 DOI: 10.4103/aian.aian_713_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 09/22/2023] [Indexed: 03/19/2024] Open
Affiliation(s)
- Ajay K. Vats
- Department of Medicine and Neurology, Consultant Neurophysician, Chaudhary Hospital and Medical Research Centre Private Limited, Udaipur, Rajasthan, India
| | - Shreya Vats
- Clinical Vestibulology Observer, Otoneurology Centre, Udaipur, Rajasthan, India
| | - Sudhir Kothari
- Department of Neurology, Poona Hospital and Research Centre, Pune, Maharashtra, India
| | - Renu Khamesra
- Associate Professor, Department of Neurology, GMCH, Udaipur, Rajasthan, India
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Chen X, Mao J, Ye H, Fan L, Tong Q, Zhang H, Wu C, Yang X. The effectiveness of the modified Epley maneuver for the treatment of posterior semicircular canal benign paroxysmal positional vertigo. Front Neurol 2023; 14:1328896. [PMID: 38187143 PMCID: PMC10771316 DOI: 10.3389/fneur.2023.1328896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
Objective To compare the repositioning effect of the modified Epley maneuver and the traditional Epley maneuver for posterior semicircular canal benign paroxysmal positional vertigo (PC-BPPV). Methods Sixty-five patients with unilateral PC-BPPV were randomly divided into two groups. The control group received the traditional Epley maneuver, while the experimental group received the modified Epley maneuver, which prolonged the time in the healthy side lying position and the final bowing position. The number of successful repositions after one, two, and three attempts and the total number of successful repositions were recorded and compared between the two groups. A BPPV virtual simulation model was used to analyze the mechanism of the modified Epley maneuver. Results The first repositioning success rate of the experimental group was significantly higher than that of the control group (85% vs. 63%, p = 0.040). The experimental group achieved 100% repositioning success rate after two attempts, while the control group needed three attempts to reach 86% repositioning success rate. Four cases in the control group experienced canal switching during the repositioning process, while none in the experimental group did. The BPPV virtual simulation model showed that the modified Epley maneuver could facilitate the passage of otoliths through the posterior arm of the posterior semicircular canal, especially through the location of obstruction. Conclusion The modified Epley maneuver is more effective than the traditional Epley maneuver in improving the single repositioning success rate and reducing the canal switching rate for PC-BPPV. This study provides a new option for the treatment of BPPV.
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Affiliation(s)
- Xiaosu Chen
- Neurology Department, Third Affiliated Hospital of Shanghai University, Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou People’s Hospital, Wenzhou, China
| | - Jiesheng Mao
- Neurology Department, Third Affiliated Hospital of Shanghai University, Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou People’s Hospital, Wenzhou, China
| | - Hua Ye
- Neurology Department, Third Affiliated Hospital of Shanghai University, Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou People’s Hospital, Wenzhou, China
| | - Luping Fan
- Rehabilitation Department, Third Affiliated Hospital of Shanghai University, Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou People’s Hospital, Wenzhou, China
| | - Qiaowen Tong
- Neurology Department, Third Affiliated Hospital of Shanghai University, Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou People’s Hospital, Wenzhou, China
| | - Hehui Zhang
- Neurology Department, Third Affiliated Hospital of Shanghai University, Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou People’s Hospital, Wenzhou, China
| | - Chengcheng Wu
- Neurology Department, Third Affiliated Hospital of Shanghai University, Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou People’s Hospital, Wenzhou, China
| | - Xiaokai Yang
- Neurology Department, Third Affiliated Hospital of Shanghai University, Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou People’s Hospital, Wenzhou, China
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Venkatramanan MAR, Harugop AS, Sankaran SA. Comparing Efficiency Epley and Semont Manoeuvre with Videonystagmography. Indian J Otolaryngol Head Neck Surg 2023; 75:3021-3026. [PMID: 37974730 PMCID: PMC10645646 DOI: 10.1007/s12070-023-03901-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/25/2023] [Indexed: 11/19/2023] Open
Abstract
Videonystagmography (VNG) is useful and reliable in diagnosing vertigo. Benign Paroxysmal Positional Vertigo (BPPV) is the most common peripheral vestibular disorder in adults, and posterior canal is the commonest canalinvolved. The treatment of choice for posterior canal BPPV is repositioning manoeuvres. Epley and Semontmanoeuvres are the two most commonly used treatment manoeuvres for the management of posterior canalBPPV. In this study, we use VNG to compare the two. Epley Repositioning Manoeuvre was found to be moreeffective than Semont Liberatory Manoeuvre. Supplementary Information The online version contains supplementary material available at 10.1007/s12070-023-03901-3.
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Affiliation(s)
- Mansi A R Venkatramanan
- Department of Otorhinolaryngology, Jawaharlal Nehru Medical College, KAHER, Belagavi, Karnataka India
| | - Anilkumar S Harugop
- Department of Otorhinolaryngology, Jawaharlal Nehru Medical College, KAHER, Belagavi, Karnataka India
| | - Sneha A Sankaran
- Department of Otorhinolaryngology, Jawaharlal Nehru Medical College, KAHER, Belagavi, Karnataka India
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di Santillo LS, Califano L. Canal switch: a possible complication of physical therapeutic manoeuvers for posterior canal benign paroxysmal positional vertigo. ACTA OTORHINOLARYNGOLOGICA ITALICA : ORGANO UFFICIALE DELLA SOCIETA ITALIANA DI OTORINOLARINGOLOGIA E CHIRURGIA CERVICO-FACCIALE 2023; 43:49-55. [PMID: 36860150 PMCID: PMC9978300 DOI: 10.14639/0392-100x-n2016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 11/15/2022] [Indexed: 03/03/2023]
Abstract
Objective To study the frequency of canal switch in posterior canal benign paroxysmal positional vertigo (BPPV) treated by canalith repositioning manoeuver (CRP), quick liberatory rotation manoeuver (QLR) or Semont manoeuver (SM). Methods Retrospective study on 1158 patients, 637 women and 521 men suffering from geotropic posterior canal BPPV treated by CRP, QLR, or SM, retested after 15 minutes and about seven days. Results 1146 patients recovered from the acute phase; treatments failed in 12 patients treated with CRP. We observed 12 canal switches from posterior to lateral canal and 2 from posterior to anterior canal during or after CRP in 13/879 cases (1.5%) and after QLR in 1/158 (0.6%) with no significant difference between CRP vs SM and QLR. We did not consider slight positional downbeat nystagmus after the therapeutic manoeuvers as a sign of canal switch into the anterior canal, but as a sign of persistent small debris in the non-ampullar arm of the posterior canal. Conclusions Canal switch is rare for any manoeuver and it does not belong to the criteria to choose one manoeuver over another. Notably, due to the canal switching criteria, SM and QLR cannot be preferred over those with a more prolonged extension of the neck.
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Affiliation(s)
- Leonardo Scotto di Santillo
- ASL 3 Genovese, S.S. Vestibology and Vestibular Rehabilitation, Genoa, Italy,Correspondence Leonardo Scotto di Santillo ASL 3 Genovese, S.S. Vestibology and Vestibular Rehabilitation, via L.A. Vassallo 3/24, 16146 Genoa, Italy E-mail:
| | - Luigi Califano
- San Pio Hospital, Department of Audiology and Phoniatrics, Benevento, Italy
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Barrett CA, Hoover DL. Differential screen and treatment of vestibular dysfunction in an elderly patient: A case report. Physiother Theory Pract 2023; 39:441-452. [PMID: 34978248 DOI: 10.1080/09593985.2021.2012858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND/PURPOSE Concussion sequelae in the elderly is under recognized and negatively impacts quality of life. Labyrinthine concussion (LC) is an uncommon diagnosis, as is multiple canal (MC) benign paroxysmal positional vertigo (BPPV). This case report highlights physical therapist (PT) evaluation and treatment of an elderly male misdiagnosed with LC and successfully treated for MC BPPV. CASE DESCRIPTION A 72 year old male presented to his PT 23 days after falling off a ladder, resulting in a mild traumatic brain injury (mTBI). Diagnosed with LC, he was referred to PT due to ongoing symptoms of "falling backwards," poor gait, and diminished mobility. PT examination revealed an atypical BPPV. Thus, the patient was treated in two PT visits, which included canalith repositioning techniques and neuromuscular reeducation. OUTCOMES The PT diagnosis was MC BPPV, including the right lateral and left posterior semicircular canals. Initial positive findings of Head Impulse Test, Bow and Lean Test, Dix-Hallpike, and Roll Test were negative on the last visit. Patient-Specific Functional Scale improved from 0 to 9.9 (10 being no limitations). The patient progressed from minimum assistance to independence in bed mobility, transfers, gait, and previous activities. DISCUSSION The patient's presentation was atypical in signs and symptoms with a diagnosis of LC. PT examination and intervention successfully resolved the patient's signs and symptoms within two visits. Further research is needed regarding identification and treatment of elderly individuals with head injuries, such as MC BPPV, as well as the efficacy of a PT seeing patients shortly after mTBI.
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Affiliation(s)
- Carrie A Barrett
- Doctor of Physical Therapy Program, Western Michigan University, Kalamazoo, MI, USA
| | - Donald L Hoover
- Doctor of Physical Therapy Program, Western Michigan University, Kalamazoo, MI, USA
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Celis-Aguilar E, Mayoral-Flores HO, Torrontegui-Zazueta LA, Medina-Cabrera CA, León-Leyva IC, Dehesa-López E. Effectiveness of Brandt Daroff, Semont and Epley maneuvers in the treatment of Benign Paroxysmal Positional Vertigo: A Randomized Controlled Clinical Trial. Indian J Otolaryngol Head Neck Surg 2022; 74:314-321. [PMID: 36213465 PMCID: PMC9535051 DOI: 10.1007/s12070-021-02516-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/15/2021] [Indexed: 11/28/2022] Open
Abstract
The aim was to compare the effectiveness of Brandt-Daroff, Semont and Epley maneuver in BPPV resolution. A Single Blind RCT in a Secondary Care Center was performed. Inclusion criteria were: patients with unilateral rotatory nystagmus on Dix-Hallpike Maneuver (DHM). Exclusion criteria: other causes of peripheral or central vertigo. Patients were randomized into 4 groups: Brandt-Daroff, "sham", Semont and Epley. Patients underwent allocation, 1st visit (at 1 week with reprise of original maneuver if persistent nystagmus) and 2nd visit (2 to 4 weeks) with repetitions of both DHM and DHI. Main Outcome Measures: Absence of nystagmus on DHM at 1st and 2nd visit evaluations and DHI score. Resolution was defined as the abscence of nystagmus. We included 34 patients (25 females, 9 males). Patients were randomized to Brandt-Daroff (n = 9), "sham" (n = 7), Semont (n = 9) and Epley (n = 9) group. Overall mean age was 59.85 years (SD ± 13.10). A total of 47.06% patients (n = 16) had negative DHM at 1st visit. Resolution for Brandt-Daroff was 22.22%, "sham" 28.57%, Semont 44.44% and Epley 88.88% (p = 0.024); at 2nd visit follow up, Epley achieved 100% resolution (other maneuvers: 42.86%, 16.67%, 44.44%, respectively. P = 0.006). The DHI improvement at 2nd visit for Brandt-Daroff was 21.17 points, "sham" 8.05, Semont 14.67 and Epley 61.78 (p = 0.001). Epley maneuver was superior to Brandt Daroff, "sham" and Semont maneuvers on nystagmus resolution and DHI improvement in patients with BPPV.
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Affiliation(s)
- Erika Celis-Aguilar
- Department of Otorhinolaryngology and Head and Neck Surgery, Center of Research and Teaching in the Health Sciences (CIDOCS), Civil Hospital of Culiacan, Autonomous University of Sinaloa, Eustaquio Buelna #91, 80030 Culiacan, Sinaloa Mexico
| | - Homero Oswaldo Mayoral-Flores
- Center of Research and Teaching in the Health Sciences (CIDOCS), Civil Hospital of Culiacan, Autonomous University of Sinaloa, 80030 Culiacan, Mexico
| | - Luis Alejandro Torrontegui-Zazueta
- Center of Research and Teaching in the Health Sciences (CIDOCS), Civil Hospital of Culiacan, Autonomous University of Sinaloa, 80030 Culiacan, Mexico
| | - Cindy Anahí Medina-Cabrera
- Center of Research and Teaching in the Health Sciences (CIDOCS), Civil Hospital of Culiacan, Autonomous University of Sinaloa, 80030 Culiacan, Mexico
| | - Ivonne Carolina León-Leyva
- Center of Research and Teaching in the Health Sciences (CIDOCS), Civil Hospital of Culiacan, Autonomous University of Sinaloa, 80030 Culiacan, Mexico
| | - Edgar Dehesa-López
- Department of Statistics, Center of Research and Teaching in the Health Sciences (CIDOCS), Civil Hospital of Culiacan, Autonomous University of Sinaloa, 80030 Culiacan, Mexico
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Wu S, Li J, Zhou M, Yang X. Simulation Study of Canal Switching in BPPV. Front Neurol 2022; 13:944703. [PMID: 35911897 PMCID: PMC9326062 DOI: 10.3389/fneur.2022.944703] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 07/17/2022] [Indexed: 11/13/2022] Open
Abstract
The objective of this research was to investigate the mechanism of canal switching in benign paroxysmal positional vertigo through a virtual simulation model. Using Unity 3D software and a built-in NVIDIA Physx physics engine, the virtual simulation software is developed using a browser-server architecture, and different models are imported. Based on the benign paroxysmal positional vertigo virtual simulation model, we constructed five different virtual reality scenes of diagnosis and treatment, set otoliths in different positions of the semicircular canals, and analyzed the effects of diagnostic and therapeutic procedures on otolith location. Through the analysis of otolith movement in five virtual scenes, we found that canal switching may be caused by otoliths in the utricle entering the semicircular canal in the supine position. Then, we used different methods to reposition the otolith, improved the repositioning maneuver, and explored in depth the mechanism of the canal switching. The results showed that the main reason for the canal switch is that in the supine position, the otolith in the utricle enters the semicircular canal. The repositioning maneuvers, including the Epley maneuver and Barbecue maneuver, will not directly lead to the canal switch in the ipsilateral inner ear. The supine roll maneuver leads to the otolith in the utricle entering the posterior or lateral semicircular canal, which is the most likely mechanism for canal switching.
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Affiliation(s)
- Shuzhi Wu
- Neurology Department, Third Affiliated Hospital of Shanghai University, Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou People's Hospital, Wenzhou, China
| | - Jianxin Li
- Third Affiliated Hospital of Shanghai University, Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou People's Hospital, Wenzhou, China
| | - Mi Zhou
- Neurology Department, Third Affiliated Hospital of Shanghai University, Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou People's Hospital, Wenzhou, China
| | - Xiaokai Yang
- Neurology Department, Third Affiliated Hospital of Shanghai University, Wenzhou Third Clinical Institute Affiliated to Wenzhou Medical University, Wenzhou People's Hospital, Wenzhou, China
- *Correspondence: Xiaokai Yang
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Single Cycle Versus Multiple Cycles of Canalith Repositioning Procedure for Treatment of Posterior Canal Benign Paroxysmal Positional Vertigo: A Randomized Controlled Trial. Otol Neurotol 2021; 42:121-128. [PMID: 32947492 DOI: 10.1097/mao.0000000000002894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare the treatment outcomes and complications of single cycle versus multiple cycles of the canalith repositioning procedure (CRP). STUDY DESIGN Randomized controlled trial. SETTING Academic tertiary referral center; Chiang Mai University, Thailand. PATIENTS One hundred and forty-three adults who had unilateral posterior canal benign paroxysmal positional vertigo (BPPV). INTERVENTION Therapeutic. Patients received either a single cycle or multiple cycles of the CRP in one session. MAIN OUTCOME MEASURES Rate of negative Dix-Hallpike test (DHT), rate of symptom improvement, dizziness handicap inventory score (DHI), and rate of complications. RESULTS At the 1st week and the 4th week recall visits after CRP the treatment outcomes between the single-CRP group and the multiple-CRP group showed no significant difference. The outcomes included: 1) rate of negative DHT (1st week: 76.9 and 76.7%, 4th week: 89.5 and 88.2%); 2) rate of complete recovery or improved symptoms (1st week: 92.3 and 91.7%; 4th week: 96.5 and 98.0%); 3) DHI scores (1st week: 22 and 28; 4th week: 6 and 10); and 4) complication rate (1st week: 12.5 and 20%; 4th week: 20 and 0%. Rate of complications in the single-CRP group (6.9%) during the 1st treatment was lower than in the multiple-CRP groups (21.1%) (p-value = 0.013). CONCLUSION A single cycle of CRP is as effective as multiple cycle CRP, with a lower incidence of complication and a decrease in the time for treatment. Single-cycle CRP is a more advantageous treatment for unilateral posterior canal BPPV. CLINICALTRIALS. GOV IDENTIFIER NCT02701218.
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Efficacy of combined canalith-repositioning procedure and supine to prolonged lateral position in treating posterior canal benign paroxysmal positional vertigo. Auris Nasus Larynx 2021; 48:834-840. [PMID: 33468353 DOI: 10.1016/j.anl.2021.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/27/2020] [Accepted: 01/07/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Posterior benign paroxysmal positional vertigo (p-BPPV) is the most common type of BPPV, and canalith-repositioning procedure (CRP) is frequently applied for treatment. Supine to prolonged lateral position (SPLP), a simple home-based maneuver, can be performed for treatment of p-BPPV. The purpose of this study was to investigate whether combination of CRP and SPLP could be more effective in symptom alleviation compared with CRP alone and reduce times of repeated CRP for patients with p-BBPV. METHODS A retrospective chart review enrolled 96 patients diagnosed with primary p-BPPV. Of these patients, 64 patients were included in the CRP group and 32 patients, in the CRP+SPLP group. The outcome was determined according to days required to reach negative result in Dix-Hallpike test, duration of vertigo and dizziness following the first repositioning procedure, and times of CRP performed to reach resolution of p-BPPV. RESULTS Of patients in the CRP and CRP+SPLP groups, 38% and 16% received CRP at least twice to reach resolution, respectively (P = 0.034). Patients in the CRP group and CRP+SPLP group spent an average of 9.8 ± 6.1 days and 7.9 ± 3.4 days, respectively reaching a negative result in Dix-Hallpike test (P = 0.050). In terms of duration for relieving vertigo and dizziness, the CRP+SPLP group achieved symptom relief with shorter duration (P = 0.036 and P = 0.025, respectively). CONCLUSION Compared with CRP alone, combination of CRP and SPLP improved the therapeutic effectiveness and shortened the duration of suffering from vertigo and dizziness in patients with p-BPPV.
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Garaycochea O, Pérez-Fernández N, Manrique-Huarte R. A novel maneuver for diagnosis and treatment of torsional-vertical down beating positioning nystagmus: anterior canal and apogeotropic posterior canal BPPV. Braz J Otorhinolaryngol 2020; 88:708-716. [PMID: 33176986 PMCID: PMC9483926 DOI: 10.1016/j.bjorl.2020.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/15/2020] [Accepted: 09/22/2020] [Indexed: 11/24/2022] Open
Abstract
Introduction In patients with benign paroxysmal positional vertigo, BPPV; a torsional-vertical down beating positioning nystagmus can be elicited in the supine straight head-hanging position test or in the Dix-Hallpike test to either side. This type of nystagmus can be explained by either an anterior canal BPPV or by an apogeotropic variant of the contralateral posterior canal BPPV Until now all the therapeutic maneuvers that have been proposed address only one possibility, and without first performing a clear differential diagnosis between them. Objective To propose a new maneuver for torsional-vertical down beating positioning nystagmus with a clear lateralization that takes into account both possible diagnoses (anterior canal-BPPV and posterior canal-BPPV). Methods A prospective cohort study was conducted on 157 consecutive patients with BPPV. The new maneuver was performed only in those with torsional-vertical down beating positioning nystagmus with clear lateralization. Results Twenty patients (12.7%) were diagnosed with a torsional-vertical down beating positioning nystagmus. The maneuver was performed in 10 (6.35%) patients, in whom the affected side was clearly determined. Seven (4.45%) patients were diagnosed with an anterior canal-BPPV and successfully treated. Two (1.25%) patients were diagnosed with a posterior canal-BPPV and successfully treated with an Epley maneuver after its conversion into a geotropic posterior BPPV. Conclusion This new maneuver was found to be effective in resolving all the cases of torsional-vertical down beating positioning nystagmus-BPPV caused by an anterior canal-BPPV, and in shifting in a controlled way the posterior canal-BPPV cases of the contralateral side into a geotropic-posterior-BPPV successfully treated during the followup visit. Moreover, this new maneuver helped in the differential diagnosis between anterior canal-BPPV and a contralateral posterior canal-BPPV.
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Affiliation(s)
- Octavio Garaycochea
- University of Navarra, Clinica Universitaria de Navarra, Department of Otorhinolaryngology, Pamplona, Spain.
| | - Nicolás Pérez-Fernández
- University of Navarra, Clinica Universitaria de Navarra, Department of Otorhinolaryngology, Pamplona, Spain
| | - Raquel Manrique-Huarte
- University of Navarra, Clinica Universitaria de Navarra, Department of Otorhinolaryngology, Pamplona, Spain
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Giannoni B, Marcelli V, Verdolin I, Checcucci C, Pollastri F, Pecci R. Congruous Torsional Down Beating Nystagmus in the Third Position of the Semont's Maneuver in Patients Treated for Canalithiasis of Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo: Its Significance and Prognostic Value. Front Neurol 2020; 11:949. [PMID: 33071926 PMCID: PMC7533572 DOI: 10.3389/fneur.2020.00949] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/22/2020] [Indexed: 11/29/2022] Open
Abstract
Due to its mechanical pathogenesis, benign paroxysmal positional vertigo treatment is mainly physical: when posterior semicircular canal is involved, Semont's maneuver is reported as one of the most effective liberating procedures. In the case of a canalolithiasis, the efficacy of the maneuver is corroborated by the appearance of some nystagmus findings during its performance. Liberating nystagmus, that can occur in the second position of Semont's maneuver and whose direction is congruous with the excitation of the affected posterior semicircular canal has proven to be a favorable prognostic sign. On the other hand, in clinical experience, we've frequently verified the appearance of another nystagmus during the execution of the maneuver: upon reaching the third position, when replacing the patient seated, a torsional down beating nystagmus, with the torsional component “congruous” with the stimulation of the vertical semicircular canals of the affected side, can often be appreciated. Such a sign can occur with or without having had the previous liberating nystagmus in the second position and is almost always associated with an intense vertigo and/or body pulsion. In this study, we describe the incidence and characteristics of the congruous torsional down beating nystagmus that can arise by assuming the third position of Semont's maneuver in a cohort of patients treated for posterior semicircular canal benign paroxysmal positional vertigo due to canalolithiasis. In the best of our knowledge, such a sign has never been described and explained before. On the basis of the pathophysiology and of the possible canal receptors stimulation during the different phases of Semont's maneuver, we formulated different hypothesis on how such a nystagmus can be generated. We observed that such a sign, when elicited, has a very good prognostic meaning for healing purposes, even better than that of liberating nystagmus. Therefore, congruous torsional down beating nystagmus should always be checked when performing Semont's maneuver because it could help in predicting success of physical treatment and in managing patients.
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Affiliation(s)
- Beatrice Giannoni
- Department of Neuroscience, Psychology, Drug's Area and Child's Health, University of Florence, Florence, Italy.,Unit of Audiology Careggi University Hospital, Florence, Italy
| | | | - Ilaria Verdolin
- Unit of Audiology Careggi University Hospital, Florence, Italy
| | - Curzio Checcucci
- Department of Physics and Astronomy, University of Florence, Italy Careggi University Hospital, Florence, Italy
| | | | - Rudi Pecci
- Unit of Audiology Careggi University Hospital, Florence, Italy
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Dai Q, Chen Q, Yin L, Zheng H, Liu SX, Duan M. The long-term follow-up of 61 horizontal canal BPPV after Gufoni and Barbecue maneuver: a prospective study. Acta Otolaryngol 2020; 140:463-466. [PMID: 32049574 DOI: 10.1080/00016489.2020.1725114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background: Horizontal canal BPPV (HC-BPPV) has a higher recurrence rate than PC-BPPV. Which maneuver is better for its prognosis is still uncertain.Objective: To compare the long-term recurrence rate after Gufoni and Barbecue maneuver.Materials and methods: We prospectively collected 61 cases of HC-BPPV which were initially diagnosed in our hospital from the first episode, and had already ruled out other diseases. Roll them into Gufoni group and Barbecue group alternatively. After the maneuver, we followed them up until December 2016. Mean follow-up time was 49.25 months.Results: The recurrence rate is 18.0% in the first year, 14.8% after the first year, and 31.1% overall. There is no statistically significant difference between Gufoni group and Barbecue group (p > .05). Age is statistically significant as a risk factor of recurrence (p<.05).Conclusions and significance: Barbecue maneuver is as good as Gufoni maneuver. The recurrence rate is only related to age. We suggest the disease relapsed within the 1st year as recurrence rather than a new disease.
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Affiliation(s)
- Qingqing Dai
- Department of Otolaryngology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
- Department of Otolaryngology Head and Neck, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
| | - Qiurong Chen
- Department of Otolaryngology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Li Yin
- Department of Medicine Epidemiology and Biostatistics, Karolinska University, Stockholm, Sweden
| | - Hong Zheng
- Department of Otolaryngology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Shi-Xi Liu
- Department of Otolaryngology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Maoli Duan
- Department of Otolaryngology Head and Neck, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
- Department of Clinical Science, Intervention and Technology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden
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Abstract
PURPOSE OF THE REVIEW To define the best up-to-date practical approach to treat benign paroxysmal positional vertigo (BPPV). RECENT FINDINGS Both posterior and horizontal canal BPPV canalith repositioning maneuvers (Semont, Epley, and Gufoni's maneuvers) are level 1 evidence treatment for evidence-based medicine. The choice of maneuver (since their efficacy is comparable) is up to the clinician's preferences, failure of the previous maneuver, or movement restrictions of the patient. Maneuvers for controversial variants, such as anterior canal and apogeotropic posterior canal BPPV, have weaker evidence of efficacy. Despite this, these variants are increasingly diagnosed and treated. Maneuvers also play a role in the differential diagnosis with central vestibular disorders. Chair-assisted treatment may be of help if available while surgical canal plugging should be indicated in selected same-canal, same-side intractable severe BPPV. The primary evidence-based treatment strategy for BPPV should be physical therapy through maneuvers. Despite the high success rate of liberatory maneuvers, there is a low percentage of subjects who have unsatisfactory outcomes. These patients need to be investigated to identify recurrences, multiple canal involvement, associated comorbidities (migraine, persistent postural perceptual dizziness), or risk factors for recurrences (low vitamin D serum level). Future research should also identify the optimum maneuvers for variants whose diagnosis and treatment are still a matter of some debate.
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Martellucci S, Attanasio G, Ralli M, Marcelli V, de Vincentiis M, Greco A, Gallo A. Does cervical range of motion affect the outcomes of canalith repositioning procedures for posterior canal benign positional paroxysmal vertigo? Am J Otolaryngol 2019; 40:494-498. [PMID: 30967256 DOI: 10.1016/j.amjoto.2019.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 03/27/2019] [Accepted: 04/02/2019] [Indexed: 01/01/2023]
Abstract
PURPOSE Canalith repositioning procedure (CRP) for posterior canal benign positional paroxysmal vertigo (BPPV), also known as Epley maneuver, is a common procedure for the treatment of BPPV. This maneuver entails flexion, extension and rotation of the patient's neck. This study aims to investigate the impact of cervical range of motion (C-ROM) on CRP efficacy. MATERIALS AND METHODS The study included 47 patients with posterior canal BPPV treated by CRP. The procedure was considered successful if vertigo and nystagmus disappeared at the post-treatment evaluation. If CRP resulted ineffective, it was repeated up to three times per session. C-ROM was measured at BPPV diagnosis before treatment. Patients were followed up for 30 days. RESULTS The first CRP was successful in 29 patients (61.7%), while it was ineffective in 18 patients (38.3%) requiring multiple repositioning maneuvers. Patients who needed two or more CRP showed lower C-ROM in extension (p = .003) and flexion (p = .042), and earlier recurrences (p = .006). Univariate regression analysis showed that lower cervical extension was significantly associated with the failure of the first CRP (OR: 0.899, 95% CI 0.831-0.973, p = .008). CONCLUSIONS Our data suggest that a reduced C-ROM can require multiple CRPs to successfully treat BPPV and increase the risk of early recurrences.
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Yang X, Ling X, Shen B, Hong Y, Li K, Si L, Kim JS. Diagnosis strategy and Yacovino maneuver for anterior canal-benign paroxysmal positional vertigo. J Neurol 2019; 266:1674-1684. [PMID: 30963252 DOI: 10.1007/s00415-019-09312-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To investigate the diagnosis strategy of anterior canal-benign paroxysmal positional vertigo (AC-BPPV) and the therapeutic effects of the Yacovino maneuver. METHODS The clinical data of 40 AC-BPPV patients were collected. The nystagmus characteristics induced by the Dix-Hallpike (D-H) and straight head-hanging (SHH) tests, the diagnostic methods used, and the effectiveness of the Yacovino maneuver for the treatment of AC-BPPV were all retrospectively analyzed. RESULTS Among the 40 cases analyzed, 19 patients had simple AC-BPPV, 11 patients had AC-posterior canal BPPV, and 10 patients had AC-horizontal canal BPPV. D-H and SHH tests showed down-beating nystagmus in 26 and 33 patients, respectively, and showed down-beating and torsional nystagmus in 14 and 7 patients, respectively. AC-BPPV was diagnosed in 15 patients based on the presence of typical BPPV in other canals, in 9 patients based on typical disease history and the results of position tests, in 6 patients based on effectiveness of the treatment with the Yacovino maneuver, in 4 patients based on the treatment effectiveness and the presence of typical BPPV in other canals, in 3 patients based on the treatment effectiveness and the follow-up outcome, in 2 patients based on the typical BPPV in other canals and occurrence of canal conversion, and in 1 patient based on the treatment effectiveness and occurrence of canal conversion. Thirteen patients with canalolithiasis and four patients with cupulolithiasis were cured after the initial Yacovino maneuver treatment. Twenty-one patients with canalolithiasis and seven patients with cupulolithiasis were cured following 1 week of treatment. CONCLUSIONS The effectiveness of the Yacovino maneuver, the follow-up outcome, the presence of typical BPPV in other canals, and the occurrence of canal conversions contribute to AC-BPPV diagnosis. The Yacovino maneuver was found to be more effective in AC-BPPV patients with canalolithiasis than in those with cupulolithiasis.
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Affiliation(s)
- Xu Yang
- Department of Neurology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, 100049, People's Republic of China.
| | - Xia Ling
- Department of Neurology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, 100049, People's Republic of China
| | - Bo Shen
- Department of Neurology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, 121001, People's Republic of China
| | - Yuan Hong
- Department of Neurology, Peking University Shougang Hospital, Beijing, 100144, People's Republic of China
| | - Kangzhi Li
- Department of Neurology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, 100049, People's Republic of China
| | - Lihong Si
- Department of Neurology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, 100049, People's Republic of China
| | - Ji-Soo Kim
- Department of Neurology, College of Medicine, Seoul National University, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam, Gyeonggi-do, 463-707, South Korea
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Ling X, Li KZ, Shen B, Si LH, Hong Y, Yang X. Diagnosis and treatment of anterior canal benign paroxysmal positional vertigo. Int J Audiol 2018; 57:673-680. [PMID: 30318958 DOI: 10.1080/14992027.2018.1472397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To investigate the diagnosis and treatment of anterior canal benign paroxysmal positional vertigo (AC-BPPV). DESIGN Retrospective analysis of clinical data regarding the diagnosis and treatment of patients with AC-BPPV. STUDY SAMPLE Six patients with AC-BPPV. RESULTS All patients underwent the Dix-Hallpike test and/or the straight head-hanging test to induce vertigo and down-beating nystagmus with or without torsional components. Down-beating nystagmus in patients 1, 3 and 6 lasted <1 min and was successfully treated with the Yacovino manoeuvre. Down-beating nystagmus in patients 2, 4 and 5 lasted >1 min. The Yacovino manoeuvre was not effective in patient 4, whereas it was effective in patient 2 but with frequently recurring symptoms. Patients 3, 4 and 6 also had other types of typical BPPV. Canal conversion appeared in patients 4 and 5 during the follow-up period. CONCLUSION Typical BPPV, canal conversion, a therapeutic diagnosis after applying the Yacovino manoeuvre, and the follow-up outcome contribute to AC-BPPV diagnosis in patients with dizziness and vertigo presenting with down-beating positional nystagmus. Yacovino manoeuvre was more effective in AC-BPPV patients with down-beating positional nystagmus lasted <1 min than in those in whom it lasted >1 min.
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Affiliation(s)
- Xia Ling
- a Peking University Aerospace School of Clinical Medicine , Beijing , PR China
| | - Kang-Zhi Li
- a Peking University Aerospace School of Clinical Medicine , Beijing , PR China
| | - Bo Shen
- b Department of Neurology , The First Affiliated Hospital of Jinzhou Medical University , Jinzhou , PR China
| | - Li-Hong Si
- a Peking University Aerospace School of Clinical Medicine , Beijing , PR China
| | - Yuan Hong
- c Department of Neurology , Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine , Beijing , PR China
| | - Xu Yang
- a Peking University Aerospace School of Clinical Medicine , Beijing , PR China
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Pérez-Vázquez P, Franco-Gutiérrez V. Treatment of benign paroxysmal positional vertigo. A clinical review. J Otol 2017; 12:165-173. [PMID: 29937852 PMCID: PMC6002633 DOI: 10.1016/j.joto.2017.08.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 08/04/2017] [Accepted: 08/07/2017] [Indexed: 11/12/2022] Open
Abstract
Benign paroxysmal positional vertigo (BPPV) is the most frequent episodic vestibular disorder. It is due to otolith rests that are free into the canals or attached to the cupulas. Well over 90% of patients can be successfully treated with manoeuvres that move the particles back to the utriculus. Among the great variety of procedures that have been described, the manoeuvres that are supported by evidenced-based studies or extensive series are commented in this review. Some topics regarding BPPV treatment, such as controlling the accuracy of the procedures or the utility of post-manoeuvre restrictions are also discussed.
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Tang H, Li W. Advances in the diagnosis and treatment of benign paroxysmal positional vertigo. Exp Ther Med 2017; 14:2424-2430. [PMID: 28962176 PMCID: PMC5609213 DOI: 10.3892/etm.2017.4837] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 05/19/2017] [Indexed: 12/03/2022] Open
Abstract
Benign paroxysmal positional vertigo (BPPV) (otolith disease) is the most common neurological and position change related vertigo, accounting for 17-20% of peripheral vertigo. BPPV occur in the elderly. The high incidence age for BPPC was 50 to 70 years and mostly in female. According to the different parts of the lesions, it is divided into anterior canal BPPV (AC-BPPV), posterior canal BPPV (PC-BPPV), horizontal canal BPPV (HC-BPPV). Studies have shown that the incidence of PC-BPPV was 86.36%, the incidence of HC-BPPV was 11.37%, the incidence rate of AC-BPPV was 2.27%. Treatment for PC-BPPV includes manual reduction, drug treatment, psychological treatment, and surgical treatment. Repositioning is the preferred method for the treatment of PC-BPPV with high effective rate and low risk. The mechanism is through the different changes of head position to make the otolith back to utricle. Many manual reduction methods have been reported in clinical treatment of PC-BPPV. With the increasing emphasis on the BPPV, a variety of new methods are being developed and designed.
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Affiliation(s)
- Hengyong Tang
- Department of Neurology, Fengcheng Hospital in Fengxian District, Shanghai, P.R. China
| | - Wei Li
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai, P.R. China
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Zhang X, Qian X, Lu L, Chen J, Liu J, Lin C, Gao X. Effects of Semont maneuver on benign paroxysmal positional vertigo: a meta-analysis. Acta Otolaryngol 2017; 137:63-70. [PMID: 27683970 DOI: 10.1080/00016489.2016.1212265] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Benign paroxysmal positional vertigo (BPPV) is the most common type of peripheral vertigo. This study aimed to evaluate the effects of the Semont maneuver (SM) for BPPV treatment, compared with other methods. METHODS Studies were selected in relevant databases under pre-defined criteria up to June 2015. The Cochrane evaluation system was used to assess the quality of the studies. Effect size was indicated as a risk-ratio (RR) with corresponding 95% confidential interval (CI). Statistical analysis was conducted under a randomized- or fixed-effects model. Sub-group analysis was performed. RESULTS Ten studies were included in the meta-analysis. All of the studies presented a low attrition bias, but a high selection and reporting bias. SM had a much higher recovery rate (SM vs no treatment: RR = 2.60, 95% CI = 1.97-3.44, p < 0.01; SM vs sham: RR = 4.89, 95% CI = 3.01-7.94, p < 0.01), and lower recurrence rate than those from controls (SM vs no treatment: RR = 0.11, 95% CI = 0.04-0.31, p < 0.01). Overall, SM had similar outcomes with Epley maneuver (EM) and Brandt-Daroff exercise (BDE) in terms of recovery rate, recurrence rate, and side-effects. CONCLUSION SM is as effective as EM and BDE for BPPV treatment.
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Tian L, Sheng HB, Wang J, Luo X, Yu J, Jia XH, Cheng X, Han Z, Chi FL. Comparative Study on the Roles of the Number of Accelerations and Rotation Angle in the Treatment Maneuvers for Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo. ORL J Otorhinolaryngol Relat Spec 2015; 78:36-45. [PMID: 26682914 DOI: 10.1159/000442091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 10/26/2015] [Indexed: 11/19/2022]
Abstract
AIMS This study aims to investigate the roles of the number of accelerations and rotation angle in the treatment of posterior semicircular canal benign paroxysmal positional vertigo (PC-BPPV). METHODS We enrolled 344 patients with unilateral PC-BPPV. Of these, 167 patients in the simple-step maneuver (SSM) group were accelerated twice and rotated 120° per step, whereas 177 patients in the multi-step maneuver (MSM) group were accelerated 4 times and rotated 60° per step. Dix-Hallpike (DH) tests were performed to categorize the treatment outcome as follows: 'symptom free' if the result was negative, 'symptom persistent' if the result remained positive after performing the maneuver 3 times or 'canal conversion' if horizontal nystagmus was evoked. RESULTS Of the patients in the SSM and MSM groups, 78.4 and 91.5% became symptom free, respectively, while canal conversion occurred in 13.8 and 5.1%, respectively (p = 0.003, χ(2) test). The success rate after performing the maneuver once was 57.1% in the MSM and 32.3% in the SSM symptom-free patients (p = 0.001, χ(2) test). One month after the treatment, 22.0 and 9.6% of the SSM and MSM patients had symptom relapse, respectively (p = 0.007, χ(2) test). CONCLUSIONS More accelerations and a smaller rotation angle improved the effectiveness and efficiency of the repositioning maneuvers and reduced canal conversion.
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Affiliation(s)
- Liang Tian
- Department of Otology and Skull Base Surgery, Eye Ear Nose and Throat Hospital, Fudan University, Shanghai Clinical Medical Center of Hearing Medicine, and Key Laboratory of Hearing Science, Ministry of Health, Shanghai, China
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22
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Abstract
Benign paroxysmal positional vertigo (BPPV), the most common cause of dizziness, occurs in all age groups. It presents with vertigo on head movement, but in older patients presentation may be typical and thus accounting for a low recognition rate in the primary care setting. It may be recurrent in up to 50% of cases. BPPV is associated with displacement of fragments of utricular otoconia into the semicircular canals, most commonly the posterior semicircular canal. Otoconia are composed of otoconin and otolin forming the organic matrix on which calcium carbonate mineralizes. Otoconia may fragment with trauma, age, or changes in the physiology of endolymph (e.g., pH and calcium concentration). Presentation varied because otoconia fragments can be displaced into any of the semicircular canals on either (or both) side and may be free floating (canalolithiasis) or attached to the cupula (cupulolithiasis). Most cases of BPPV are idiopathic, but head trauma, otologic disorders, and systemic disease appear to be contributory in a subset. Positional maneuvers are used to diagnose and treat the majority of cases. In rare intractable cases surgical management may be considered. A strong association with osteoporosis suggests that idiopathic BPPV may have diagnostic and management implications beyond that of a purely otologic condition.
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