Chapter 26 Benign paroxysmal positional vertigo (BPPV) is an extremely common peripheral vestibular disorder. The origins of this pathology from free-floating particles in the posterior semicircular canal are well documented. Standard treatment is physical therapy utilizing particle-repositioning maneuvers. Physical therapeutic maneuvers successfully manage greater than 90% of patients with one or two attempts.1 Patients who have failed particle-repositioning maneuvers and still have clear and persistent BPPV symptoms remain a clinical challenge. For a select group of patients, posterior semicircular canal (PSCC) occlusion is a therapeutic alternative.2 This procedure involves the obliteration of the PSCC, and thus, prevents the canal from being motion sensitive. Success rates for this procedure for the symptoms of vertigo are reported near 100% in several studies.3 BPPV manifests with a classic set of signs and symptoms. The classic symptoms are positional vertigo with the absence of hearing changes. Physical examination reveals the following: 1. Clockwise nystagmus with the left ear down during Dix-Hallpike maneuver 2. Counterclockwise nystagmus with the right ear down during Dix-Hallpike maneuver 3. Latency of 2 to 10 seconds 4. Fatigability 5. Vertigo 6. Reversal with sitting It is essential that rotary nystagmus is observed during the Dix-Hallpike maneuver, confirming that the pathology is indeed from the PSCC. Standard treatment with one or two Epley maneuvers successfully treats patients in the low 90% range.1 Of the remaining patients, only a small subset will have symptoms troubling enough to warrant surgical intervention. The two indications for PSCC occlusion after at least two particle-repositioning maneuvers have failed are as follows4: 1. Continuous symptoms for greater than 3 months 2. Recurrent symptomatic BPPV for 12 months or greater5 1. Only hearing or significantly better hearing ear 2. Active otomastoiditis The history should focus on confirming the diagnosis of BPPV as well as ruling out bilateral disease. Approximately 15% of patients may have bilateral BPPV.3 Treatment should focus on the most symptomatic side first unless it is the significantly better hearing ear. Physical exam should include a complete neurootologic exam with audiometry, electronystagmography (ENG) to confirm PSCC involvement, and magnetic resonance imaging (MRI) to rule out central pathology, and some clinicians request a variety of otologic-related metabolic labs.6 A complete workup is essential before proceeding to the operative suite.
POSTERIOR SEMICIRCULAR CANAL OCCLUSION FOR BENIGN PAROXYSMAL POSITIONAL VERTIGO
DIAGNOSIS AND INDICATIONS
CONTRAINDICATIONS
PREOPERATIVE EVALUATION
