By Dr. Yoon Jeon, MChiro, MB, BSc, Dip.TCM, PGCert.
Case Presentation
A 34-year-old female presented to the clinic with an acute episode of vertigo, described as a sensation of the room spinning, accompanied by severe nausea.
Symptoms began that morning immediately after stretching upon waking. The initial episode gradually reduced over approximately 2 hours and was clearly position-related.
There was no associated neurological deficit or other systemic symptoms.
Clinical Examination
Dix-Hallpike testing for the right posterior semicircular canal reproduced symptoms, with a mild torsional counter-clockwise nystagmus observed.
All other orthopaedic and neurological examinations were unremarkable.
Initial diagnosis: Benign Paroxysmal Positional Vertigo (BPPV) – right posterior semicircular canal involvement.
Initial diagnosis: Benign Paroxysmal Positional Vertigo (BPPV) – right posterior semicircular canal involvement.
Initial Treatment
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Epley’s manoeuvre (canalith repositioning procedure)
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Home-based Brandt-Daroff exercises
Initial Outcome
The patient initially responded well, reporting complete resolution of vertigo symptoms following Epley’s manoeuvre.
However, one week later, she re-presented with recurrence and progression of symptoms beginning the previous day.
Reassessment
Repeat Dix-Hallpike testing of the right posterior canal again elicited symptoms; however, this time a prominent horizontal nystagmus was observed.
Further examination in the supine position with the head flexed at 30° revealed:
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Prominent geotropic nystagmus (fast phase towards the dependent ear) on right head rotation
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Short latency of 1–5 seconds before onset
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Fatigability of nystagmus within <30 seconds
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Increased symptom reproduction on right rotation compared to left
Due to severity, full suppression of nystagmus with positional change was not achievable.
Revised Diagnosis
Findings were consistent with:
Lateral (horizontal) semicircular canal BPPV (LSC-BPPV)
This is a less common variant, accounting for approximately 2–15% of BPPV cases.
The side with the most prominent nystagmus and symptom reproduction was identified as the affected side.
Revised Management
A modified canalith repositioning approach was implemented, including:
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Vannucchi method: prolonged positioning on the unaffected side (≥12 hours)
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Lempert / “Log-roll” manoeuvre: sequential 90° rotations in the supine position
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Barrel-roll (360° roll technique): controlled full-body rotation towards the unaffected side
Home exercise guidance was also reinforced.
Clinical Outcome
Following two additional treatment sessions:
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Significant reduction in vertigo episodes
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Progressive resolution of positional symptoms
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Improved balance and functional stability
At the fourth visit:
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The patient was completely asymptomatic
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Full functional recovery achieved
Discussion
Etiology
Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of peripheral vertigo. It was first described by Bárány in 1921.
Anatomy & Physiology
The vestibular system detects head position and movement via three semicircular canals arranged orthogonally. These canals contain endolymph fluid and a sensory structure called the cupula, which responds to angular acceleration.
Displacement of endolymph stimulates hair cells, producing excitatory or inhibitory neural signals depending on movement direction.
Pathophysiology
BPPV occurs when otoconia (calcium carbonate crystals) become displaced from the utricle and enter the semicircular canals.
Two main subtypes exist:
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Canalithiasis: free-floating otoconia within the canal (most common)
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Cupulolithiasis: otoconia adhered to the cupula
This disrupts normal vestibular signalling, leading to asymmetric input between the two inner ears. The brain interprets this mismatch as:
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Vertigo (illusion of movement)
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Nystagmus (involuntary eye movements)
Clinical Course & Management
BPPV is often self-limiting, with spontaneous resolution reported within several weeks (average ~10 weeks in some studies).
First-line management includes:
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Canalith repositioning manoeuvres (e.g. Epley, Lempert)
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Brandt-Daroff home exercises
Surgical intervention is rarely required and reserved for refractory chronic cases.
Conclusion
This case demonstrates the importance of recognising variant forms of BPPV, particularly lateral canal involvement following initial posterior canal presentation.
While Epley’s manoeuvre is highly effective for posterior canal BPPV, treatment must be adapted when symptoms evolve.
Conservative management using appropriate repositioning techniques remains highly effective, safe, and first-line in the management of BPPV.
REFERENCES
D’Agostino, R, Melagrana, A, Taborelli, G. (2003) Benign Paroxysmal Positional Vertigo of horizontal semicircular canal in the child: case report. Int. Journal of Pediatric Otrhinolaryngology; 67: 549-551.
Parnes, LS, Agrawal, SK, Atlas, J. (2003) Diagnosis and Management of Benign Paroxysmal Positional Vertigo (BPPV).
Canadian Medical Association Joumal; 169(7): 681-693
White, JA, Coale, K, Catalano, PJ, Oas, JG. (2005) Diagnosis and Management of Lateral Semicircular Canal Benign
Paroxysmal Positional Vertigo. Otolaryngology — Head and Neck surgery; 133: 278-284.
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