By Dr. Yoon Jeon, MChiro, MB, BSc, Dip.TCM, PGCert.
A 34 year old lady presented to the clinic with with an acute episode of vertigo (feeling of spinning in the room), accompanied by severe nausea. The symptoms started that same morning after stretching herself out whilst waking up. The vertigo decreased after 2 hours and was positioning related.
On physical examination, The Dix-Hallpike test for the right posterior canal reproduced her symptoms with a mild torsional counter-clockwise-beating nystagmus visible. Other Orthopaedic and Neurological Tests are unremarkable.
Initial Diagnosis: Benign paroxysmal positional vertigo (BPPV) of the right posterior semicircular canal.
Epley’s manoeuvre for canalith repositioning.
Self-home the particle repositioning (Brandt-Daroff)exercises.
The same patient booked back in again one week later with progression of symptoms since the previous day. She had been vertigo-free since Epley's manoeuvre was performed. Testing of the right posterior semicircular canal with Dix-Hallpike’s Test was again positive. But this time a very prominent horizontal nystagmus was observed. Further, testing in the supine position with the head in 30° flexion revealed a prominent geotrophic nystagmus (fast-phase towards the underlying ear) on right rotation of the head. A short latency of 1-5s was observed before nystagmus onset, and the nystagmus fatigued after <30s. Reduction of the nystagmus on flextion, as typical in peripheral causes, was not possible due to the severity of the nystagmus. Left rotation of the head led to vertigo and a less strong geotrophic nystagmus.
This intense vertigo with a horizontal geotrophic nystagmus that changes direction on head rotation to both sides, is typical of a somewhat rarer form of BPPV; lateral semicircular canal(LSC) BPPV. LSC-BPPV occurs in 2-15% of the BPPV cases. The side with the most prominent nystagmus and most severe symptom reproduction is considered to be side of involvement.
Modified canalith repositioning manoeuvres for the lateral semicircular canal, also depending on the severity of the occurring symptoms:
- Vanucchi method: lying on the unaffected ear for at least 12 hours to stimulated spontaneous
- “Log-roll procedure" as described by Lempert and Tiel-Wilck
- Epley’s “Barrel-roll" or “360°-roll": patient is rolled in 90° increments from a supine position to a supine position towards the unaffected ear.
The patient has an improvement significantly after two more visits. On the 4th visit, she was asymptomatic & fully functioned.
Benign paroxysmal positional vertigo is the most common inner ear disease leading to vertigo. The condition was first described in 1921 by Barany. lt's the most common cause of peripheral vertigo.
Anatomy and Physiology
The vestibular apparatus monitors motion and position of the head in space by detecting linear and angular accelerations. The three semi-circular canals, each positioned perpendicular to each other, detect angular acceleration. Each canal is filled with fluid called endolymph. Each canal consists of an ampulla, which holds the neural sensitive organ the cupula with its attached hair cells. Movement of the endolymph and thus the cupula will cause the hair cells to bend. Depending on the direction of movement of the endolymph and the particular semicircular canal, defection of the hair cells will cause either an excitatory or inhibitory response.
Subtypes of BPPV
- Canalithiasis: loose otoconia from the macula in the utricle find their way into one of the semicircular canals. Most common is the dependent posterior canal; a rarer variant involves the lateral/horizontal canal. Very rare is involvement of the superior/anterior canal.
- Cupulolithiasis: loose otoconia attach to the cupula, sensitizing the organ.
Vertigo occurs because of the push-pull mechanisms of the bilateral vestibular apparatus. ln normal instances an excitatory stimulus in one of the canals of the left vestibular apparatus would cause a reciprocal inhibitory stimulus of that same canal on the right. In the case of BPPV, an excitatory or inhibitory firing of the hair cells due to loose otoconia floating in the canal will not be balanced by a reciprocal response in the same canal on the right.
This will lead to a dis-organisation of stimuli in the brain, which will be translated into a true vertigo by the brain; the sensation of spinning of either the person in the room or the room around the person.
A second result of this dis-organisation of neural firing is nystagmus.
BPPV can be treated by the Epley manoeuvre by a health practitioners with Brandt-Daroff self-exercises
The condition goes away on its own after several weeks or months even without any treatment. One study said the condition had resolved in many people with BPPV in an average of 10 weeks.
Surgery is very rare If symptoms persist for months or years and cannot be eased, an operation of the inner ear to take out the function of the posterior semicircular canal may then be an option.
A conservative treatment with the self-exercise is excellent care for BPPV, however the manoeuvour should be modified carefully depend on progression of symptoms.
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