This induces movement of the particulate matter in the posterior semicircular canal by gravity, leading to rotatory nystagmus toward the lower ear that extinguishes after a brief interval. The illustration shows the treatment of BPPV due to canalolithiasis of the right posterior semicircular canal.Ī) In the initial, sitting position, the head is turned 45° to the side of the unaffected ("healthy") ear.ī) The patient is laid on the right side, i.e., on the side of the affected ear, while the head is kept in 45° of rotation to the other side. The symptoms eventually recur at some time after effective treatment in about 50% of patients ( 7) but can then be treated effectively a second time in the same manner.įigure 1: The treatment of benign paroxysmal positioning vertigo (BPPV) with the Semont maneuver. The rate of recurrence of BPPV is about 15% to 30% per year. The two are equally effective, and the cure rate is more than 95% within a few days, as shown by multiple controlled studies and meta-analyses ( 6). Most patients can perform these maneuvers themselves after brief training. For the Semont maneuver, see figure 1 the Epley maneuver involves rotation of the patient in the recumbent position with the head hanging down. ![]() The treatments of choice are the Semont ( 5) and Epley maneuvers. According to this hypothesis, the condition is due to the presence of agglomerates of many otoconia that nearly fill the lumen of the semicircular canal and are freely mobile within it, instead of the small pieces of particulate matter that adhere firmly to the cupula (so-called cupulolithiasis).īPPV is treated with positioning maneuvers: rapid repositioning of the head can move the otoconial agglomerate out of the semicircular canal so that it can no longer cause positioning vertigo. The canalolithiasis hypothesis explains all of the manifestations of positioning vertigo and nystagmus ( 4). If left untreated, it persists in about 30% of patients. BPPV is called "benign" because it usually resolves spontaneously within a few weeks or months in some cases, however, it can last for years. BPPV of the horizontal semicircular canal is rare and is precipitated by rotation of the head in the recumbent position. BPPV also arises with greater than usual frequency after prolonged bed rest necessitated by other diseases, or after surgery. More than 90% of cases are idiopathic the remaining, symptomatic cases are most commonly due to head trauma, vestibular neuritis, or Menière’s disease ( 3). The nystagmus corresponds to a so-called ampullofugal excitation of the affected posterior vertical semicircular canal of the affected (lower) ear. After a change in position of one of these types, rotational vertigo and nystagmus arise after a latency of a few seconds and then take a characteristic crescendo-decrescendo course, lasting a total of 30 to 60 seconds. The attacks are precipitated by reclination of the head, or by lateral positioning of the head or body, with the affected ear downward. It is characterized by brief attacks of rotational vertigo, accompanied by vertical positioning nystagmus that rotates toward the lower of the two ears and beats toward the forehead. This is the most common type of vertigo it mainly affects older patients ( table 1) and has a lifetime prevalence of 2.4% ( 1). ![]() The important criteria for distinguishing among them are as follows ( 2):īenign paroxysmal positioning vertigo (BPPV) The relative frequencies of various syndromes presenting with dizziness and vertigo are listed in table 1. Ancillary testing is of secondary importance. In other words, these patients often fall into the cracks between medical specialties.Ī patient’s complaint of "dizziness" necessitates the taking of a thorough history precisely because of the many different meanings this term can have. Experience has shown that the affected persons often make an odyssey of visits to physicians belonging to various specialties, beginning with their family physicians and proceeding through ENT specialists, neurologists, ophthalmologists, internists, and orthopedists, before the correct diagnosis is made and the appropriate treatment is begun. Their lifetime prevalence is approximately 20% to 30% ( 1). Alongside headache, dizziness and vertigo are among the more common symptoms with which patients present to physicians in general, not just to neurologists. The term "dizziness" refers either to an unpleasant disturbance of spatial orientation or to the erroneous perception of movement, which is more specifically called "vertigo." Vertigo involves a perceived movement either of one’s own body, such as swaying or rotation, or of the environment, or both.
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