Abstract
Purpose
The aims of this study were to describe the frequency and clinical features of benign paroxysmal positional vertigo (BPPV) with multiple canal involvement and to evaluate the results of treatment by appropriate canalith repositioning procedures.
Materials and Methods
A total of 345 patients were referred for BPPV between 2006 and 2010. Thirty-two of them (9.3%) who had BPPV of multiple canals were studied. Thirteen were men (mean age, 60.4 years) and 19 were women (mean age, 56.8 years). Dix-Hallpike and supine roll tests were performed for diagnosis. Canalith repositioning procedures for treatment included modified Epley, barbecue, Gufoni, and anterior BPPV-specific maneuvers.
Results
Twenty-one patients had bilateral posterior canal BPPV, and 11 had mixed canal BPPV either on the same side (7 patients) or on both sides (4 patients). Thirty-one patients were cured with an average of 2.9 therapeutic sessions per patient. Recurrences occurred in 5 patients (15.6%).
Conclusions
Benign paroxysmal positional vertigo of multiple canals is not rare and presents a clinical challenge. However, accurate diagnosis results in successful treatment comparable with BPPV of 1 canal.
1
Introduction
Benign paroxysmal positional vertigo (BPPV) is one of the most common clinical entities encountered in a neurotology clinic . This disorder is associated with a characteristic paroxysmal positional nystagmus, which may be torsional, vertical, or horizontal, and is characterized by findings such as latency, crescendo and decrescendo, transience, reversibility, and fatiguability . Although in most cases of BPPV the posterior canal is involved, BPPV of the horizontal canal occurs in a smaller rate, ranging from 5% to 30% according to various reports , and more rarely, involvement of the anterior canal may be observed .
Disease of multiple canals, either bilaterally or on the same side, represents a small fraction only of the patients with BPPV, but their presentation is quite interesting because of the various diagnostic and therapeutic challenges arising. In several studies , such cases have been occasionally reported, but the various pathogenetic and diagnostic issues need further discussion. The aim of this study is to present a series of patients with BPPV with multiple canal involvement diagnosed and treated in the Neurotology Unit of an Otolaryngology department during the last 5 years. I intended also to present an in-depth discussion of the nystagmus characteristics, which should be useful in differential diagnosis, and to present the problems arising, especially in bilateral same canal involvement.
2
Patients and methods
During the past 5 years (2006-2010), 345 patients examined at the neurotology unit of our department received diagnoses of BPPV. Thirty-two patients among them presented with BPPV of multiple canals and were included in the study. Their clinical records were retrospectively reviewed, and their age, sex, and the etiology and duration of their symptoms were recorded. Another 12 patients with possible multiple canal BPPV were excluded because of missing data and lack of follow-up or clinical examination, laboratory findings, and imaging studies suggesting pathologic conditions of the central nervous system.
All patients underwent a complete otolaryngologic, audiological, and neurotologic evaluation, including pure-tone audiometry, measurements of acoustic immitance, and occasionally, auditory brainstem response. Eye movements were recorded by electronystagmography or videonystagmography using a standard test protocol of visual and vestibular stimulation described elsewhere .
Posterior or anterior canal BPPV were diagnosed with the help of the Dix-Hallpike maneuver. Intense vertigo accompanied by a burst of nystagmus with the typical characteristics of latency, crescendo, and transience was considered necessary to establish the diagnosis. A diagnosis of posterior canal involvement was based on the type of the paroxysmal positioning nystagmus produced during the Dix-Hallpike maneuver. The direction of the vertical component of the fast phase of the nystagmus response should be upward, and the torsional component of the nystagmus should be beating toward the “downside” affected ear: movement of the upper pole of the eye counterclockwise during the right Dix-Hallpike maneuver when the right ear was involved and clockwise during the left Dix-Hallpike maneuver when the left ear was involved. Dix-Hallpike maneuver positive toward 1 side only, with the previously described features of nystagmus, denoted involvement of the posterior canal of the same side, whereas presence of a bilaterally positive maneuver implied bilateral posterior canal involvement .
Anterior canal involvement was also characterized by paroxysmal positioning nystagmus with both a predominant linear component and a slight torsional component. Differential diagnosis between posterior and anterior canal disease was based on the direction of the vertical component of the fast phase of the nystagmus, being upward in cases of posterior canal involvement and downward in cases of anterior canal disease. The direction of the torsional component of the nystagmus is the key element to the identification of the involved side in patients with BPPV of the anterior canal. When the torsional component of the nystagmus was similar in direction with that of posterior canal BPPV, then involvement of the anterior canal of the same side at which the Dix-Hallpike maneuver was performed might be inferred. When the torsional component of the nystagmus had the opposite direction, disease of the contralateral anterior canal was implied .
Finally, the horizontal canal type of vertigo was diagnosed by the presence of horizontal geotropic or apogeotropic paroxysmal nystagmus provoked by the supine roll test, performed by turning the head from the supine to either lateral position. The geotropic type of horizontal nystagmus denoted canalolithiasis of the lateral canal on the side with the more intense nystagmus, whereas the apogeotropic variety was indicative of cupulolithiasis (or canalolithiasis of the short arm of the lateral canal) on the side with the less intense nystagmus . In Table 1 , the diagnostic features of the positional nystagmus for each type of BPPV, according to the canal involved, are shown. Diagnosis of multiple canal BPPV is based on combination of these findings.
| Vertical SC canals | ||||
|---|---|---|---|---|
| Involved SC canal | Diagnostic maneuver | Paroxysmal positioning nystagmus | ||
| Vertical | Torsional | |||
| P-BPPV R | Dix-Hallpike R (+) | Upbeating | Counterclockwise | |
| Dix-Hallpike L (−) | No nystagmus | |||
| P-BPPV L | Dix-Hallpike R (−) | No nystagmus | ||
| Dix-Hallpike L (+) | Upbeating | Clockwise | ||
| A-BPPV R | Dix-Hallpike R (+) | Downbeating | Counterclockwise | |
| Dix-Hallpike L (+) | Downbeating | Counterclockwise | ||
| A-BPPV L | Dix-Hallpike R (+) | Downbeating | Clockwise | |
| Dix-Hallpike L (+) | Downbeating | Clockwise | ||
| Horizontal SC canals | ||||
|---|---|---|---|---|
| Direction of nystagmus | Intensity of nystagmus | Pathogenetic mechanism | ||
| H-BPPV | Supine roll test ipsilateral (+) | Geotropic | More intense | Canalolithiasis |
| Supine roll test contralateral (+) | Geotropic | Less intense | ||
| H-BPPV | Supine roll test ipsilateral (+) | Apogeotropic | Less intense | Cupulolithiasis or canalolithiasis of the short arm of the horizontal SC |
| Supine roll test L contralateral (+) | Apogeotropic | More intense | ||
Posterior canal BPPV was treated by the modified Epley canalith repositioning procedure (CRP) . Anterior canal BPPV was treated by the reverse Epley or a maneuver specifically invented for this canal . Briefly, this maneuver, which is an Epley variation, begins with the head-hanging position and maximal neck extension with torsion of the head 45° to the affected side, obtaining thus slight movement of otoconia toward the top of the canal. Next, by turning the patient’s head 90° toward the healthy side in head-hanging position, otoconia are expected to move further toward the utricle. The CRP ends with quick return to the sitting position, expecting movement of otoconia into the utricle because of the synergic action of gravity and angular acceleration. All 3 steps of the maneuver are maintained for 1 minute. Finally, horizontal canal BPPV was treated by the barbecue or the Gufoni maneuver, in case of geotropic or apogeotropic nystagmus, respectively . Repeat sessions each 2 days were held, treating 1 only canal during each session, or repeating previous therapeutic CRPs if incomplete remission of the symptoms was noticed. The order of application of the appropriate CRP, according to the involved canal, was horizontal, posterior, and anterior canal. The horizontal canal BPPV was treated first because it is known to present with more intense symptoms . Assessment of the success of the treatment included both the patient’s report of relief from vertigo and a negative Dix-Hallpike test or supine roll test result, for at least 2 months. Follow-up care included visits every 6 months or earlier in case the symptoms recurred. In such cases, the repositioning procedures were repeated according to the same plan. After 2 years of absence of symptoms, it was considered that definite cure had been achieved. Follow-up data were available for most patients for more than 2 years.
2
Patients and methods
During the past 5 years (2006-2010), 345 patients examined at the neurotology unit of our department received diagnoses of BPPV. Thirty-two patients among them presented with BPPV of multiple canals and were included in the study. Their clinical records were retrospectively reviewed, and their age, sex, and the etiology and duration of their symptoms were recorded. Another 12 patients with possible multiple canal BPPV were excluded because of missing data and lack of follow-up or clinical examination, laboratory findings, and imaging studies suggesting pathologic conditions of the central nervous system.
All patients underwent a complete otolaryngologic, audiological, and neurotologic evaluation, including pure-tone audiometry, measurements of acoustic immitance, and occasionally, auditory brainstem response. Eye movements were recorded by electronystagmography or videonystagmography using a standard test protocol of visual and vestibular stimulation described elsewhere .
Posterior or anterior canal BPPV were diagnosed with the help of the Dix-Hallpike maneuver. Intense vertigo accompanied by a burst of nystagmus with the typical characteristics of latency, crescendo, and transience was considered necessary to establish the diagnosis. A diagnosis of posterior canal involvement was based on the type of the paroxysmal positioning nystagmus produced during the Dix-Hallpike maneuver. The direction of the vertical component of the fast phase of the nystagmus response should be upward, and the torsional component of the nystagmus should be beating toward the “downside” affected ear: movement of the upper pole of the eye counterclockwise during the right Dix-Hallpike maneuver when the right ear was involved and clockwise during the left Dix-Hallpike maneuver when the left ear was involved. Dix-Hallpike maneuver positive toward 1 side only, with the previously described features of nystagmus, denoted involvement of the posterior canal of the same side, whereas presence of a bilaterally positive maneuver implied bilateral posterior canal involvement .
Anterior canal involvement was also characterized by paroxysmal positioning nystagmus with both a predominant linear component and a slight torsional component. Differential diagnosis between posterior and anterior canal disease was based on the direction of the vertical component of the fast phase of the nystagmus, being upward in cases of posterior canal involvement and downward in cases of anterior canal disease. The direction of the torsional component of the nystagmus is the key element to the identification of the involved side in patients with BPPV of the anterior canal. When the torsional component of the nystagmus was similar in direction with that of posterior canal BPPV, then involvement of the anterior canal of the same side at which the Dix-Hallpike maneuver was performed might be inferred. When the torsional component of the nystagmus had the opposite direction, disease of the contralateral anterior canal was implied .
Finally, the horizontal canal type of vertigo was diagnosed by the presence of horizontal geotropic or apogeotropic paroxysmal nystagmus provoked by the supine roll test, performed by turning the head from the supine to either lateral position. The geotropic type of horizontal nystagmus denoted canalolithiasis of the lateral canal on the side with the more intense nystagmus, whereas the apogeotropic variety was indicative of cupulolithiasis (or canalolithiasis of the short arm of the lateral canal) on the side with the less intense nystagmus . In Table 1 , the diagnostic features of the positional nystagmus for each type of BPPV, according to the canal involved, are shown. Diagnosis of multiple canal BPPV is based on combination of these findings.
| Vertical SC canals | ||||
|---|---|---|---|---|
| Involved SC canal | Diagnostic maneuver | Paroxysmal positioning nystagmus | ||
| Vertical | Torsional | |||
| P-BPPV R | Dix-Hallpike R (+) | Upbeating | Counterclockwise | |
| Dix-Hallpike L (−) | No nystagmus | |||
| P-BPPV L | Dix-Hallpike R (−) | No nystagmus | ||
| Dix-Hallpike L (+) | Upbeating | Clockwise | ||
| A-BPPV R | Dix-Hallpike R (+) | Downbeating | Counterclockwise | |
| Dix-Hallpike L (+) | Downbeating | Counterclockwise | ||
| A-BPPV L | Dix-Hallpike R (+) | Downbeating | Clockwise | |
| Dix-Hallpike L (+) | Downbeating | Clockwise | ||
| Horizontal SC canals | ||||
|---|---|---|---|---|
| Direction of nystagmus | Intensity of nystagmus | Pathogenetic mechanism | ||
| H-BPPV | Supine roll test ipsilateral (+) | Geotropic | More intense | Canalolithiasis |
| Supine roll test contralateral (+) | Geotropic | Less intense | ||
| H-BPPV | Supine roll test ipsilateral (+) | Apogeotropic | Less intense | Cupulolithiasis or canalolithiasis of the short arm of the horizontal SC |
| Supine roll test L contralateral (+) | Apogeotropic | More intense | ||
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