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Stavros Korres1
Maria Riga2
Vasilios Sandris3
Vasilios Danielides2
Aristides Sismanis1
1ENT Department, Hippokration
Hospital, University of Athens, Greece
2ENT Department, University Hospital
of Alexandroupolis, Democritus
University of Thrace, Greece
3ENT Department, General Hospital of
Larissa, Greece
Key Words
Anterior semicircular canal
Canalithiasis
Repositioning manoeuvres
Abbreviations
ASC: Anterior semicircular canal
BPPV: Benign paroxysmal positional
vertigo
D-H: Dix-Hallpike
Sumario
Benign paroxysmal positional vertigo (BPPV) of the anterior semicircular canal (ASC) is an uncommon disorder currently diagnosed with the Dix-Hallpike (D-H) examination.
According to the literature, nystagmus and vertigo may be
more pronounced when the affected ear is either up or down.
In some patients, both right and left D-H tests can trigger
nystagmus with the same direction. The proposed treatment
options with the addition of a different manoeuvre applied
by the authors of the present study in cases of ASC lithiasis,
seem to present a respective variety regarding the position
of the affected ASC during the procedure of canalith repositioning. The aim of this study is to analyse the mechanisms underlying both the proposed treatment options and
the clinical findings in the D-H examination. The results of
this analysis stimulate further investigation, since they probably imply that repositioning manoeuvres might vary in their
effectiveness when applied to different clinical subgroups of
ASC BPPV.
Benign paroxysmal positional vertigo (BPPV) of the anterior semicircular canal (ASC) is an uncommon disorder of the vestibular organ (Herdman et al, 1994; Katsarkas, 1999). This is probably due to the fact that
gravity restricts the upward movement of the debris, while facilitating
self-clearance through the posterior arm of the ASC into the common
crus and vestibule (Korres et al, 2002). In addition to being a relatively
rare condition, determining the affected side based on the Dix-Hallpike
(D-H) examination can often be difficult, thus complicating proper diagnosis and treatment (Korres et al, 2008; Bronstein, 2003).
The modified Epley particle repositioning procedure (Jackson
et al, 2007; Lopez-Escamez et al, 2006), as well as the reverse Epley
(Honrubia et al, 1999; Epley, 2001; Seok et al, 2008), have each been
proposed for the treatment of ASC BPPV. A different manoeuvre has
been reported by Rahko (2002). Kim et al (2005) have suggested a
repositioning manoeuvre resembling the D-H test, and Hamid (2001)
has reported the observation that in the cases he had diagnosed, ASC
BPPV had resolved with performing the D-H examination several
times to check for fatigability. Crevits (2004) has proposed a prolonged forced position procedure and Yacovino et al (2009) proposed
a different manoeuvre based on the head-straight neck hyperextension. An additional manoeuvre, roughly resembling also the D-H test,
but with differences in the microforces provoking the movement of
otoconia, is proposed by the authors of this study.
The aim of this study is to review the various treatment options of
ASC canalithiasis and through the understanding of their underlying
mechanisms attempt to identify findings in the D-H examination
which may indicate proposed repositioning manoeuvres. A new
ISSN 1499-2027 print/ISSN 1708-8186 online
DOI: 10.3109/14992021003753490
2010 British Society of Audiology, International
Society of Audiology, and Nordic Audiological Society
Received:
April 6, 2009
Accepted:
March 6, 2010
Figure 1. The reverse Epley manoeuvre for the treatment of left ASC canalithiasis. (A) The procedure begins with the patient sitting with
the head turned 45 to the healthy (right) ear. (B) Then, the patients body is quickly brought back, into a slight head-hanging position,
keeping the head turned to the same side. (C) The head is then slowly rotated toward the affected (left) ear, which is now lowermost. (D)
The patient is then rolled to a side-lying position, with the head turned 45 additionally toward the left ear, and downward to the floor. (E)
Finally, the patient is brought slowly back to the sitting position.
30 seconds the head is turned further upwards 45, so that the patient
faces straight up (Figure 2D). Finally the patient sits up and stays there
well supported for at least three minutes (Figure 2E).
The modified Epley particle repositioning procedure with or without use of vibration is an alternative therapeutic suggestion (Jackson
et al, 2007; Lopez-Escamez et al, 2006). This procedure begins with
the patient sitting with the head turned 45 to the affected ear (Figure 3A). Then, the patients body is quickly brought back, into a
slight head-hanging position, keeping the head turned to the same
side (Figure 3B). The head is then slowly rotated toward the unaffected ear, which is now lowermost (Figure 3C). The patient is then
rolled to a side-lying position, with the head turned 45 additionally
toward the healthy ear, and downward toward the floor (Figure 3D).
Finally, the patient is brought slowly back to the sitting position
(Figure 3E). Jackson et al (2007) reported that the application of this
canal repositioning procedure in a large population of 55 patients
was required 1.32 times in order to resolve ASC BPPV. The same
authors have reported a nearly double the highest incidence of ASC
Figure 2. The manoeuvre proposed by Rahko (2002) (the black arrows represent the gravitational force on otoconia). The left ASC is
affected. (A) The patient lies on the healthy side for 30 seconds. (B) The head is tilted downwards 45 (facing the floor for 30 seconds
more). (C) Then the head is tilted further 180. Thus, at the end of this phase the patients head is found turned 45 toward the affected side.
The patient remains in this position for 30 seconds more. (D).The head is tilted upwards 45 and for 30 seconds more the patient is facing
straight up. (E) Finally the patient sits up and stays there well supported for at least three minutes.
Korres/Riga/Sandris/Danielides/Sismanis
607
Figure 3. The modified Epley particle repositioning procedure. The left ASC is affected. (A) This procedure begins with the patient sitting
with the head turned 45 to the affected ear. (B) Then, the patients body is quickly brought back, into a slight head-hanging position, keeping
the head turned to the same side. (C) The head is then slowly rotated toward the unaffected ear, which is now lowermost. (D) The patient
is then rolled to a side-lying position, with the head turned 45 additionally toward the healthy ear, and downward to the floor. (E) Finally,
the patient is brought slowly back to the sitting position.
is lowered to a supine position with the head hanging off 30 at
the end of the bed for two minutes (Figure 5B). Next, the patients
head is elevated in a supine position while the head remains turned
45 for one minute (this step is not included in a D-H examination)
(Figure 5C). Finally, the patient is returned to a sitting position and
his chin is tilted 30 down (Figure 5D). The manoeuvre is based
on the fact that ampullary endings of the ASC are lateral and the
non-ampullary endings are medial (Brantberg & Bergenius, 2002).
This manoeuvre has been reported to resolve the nystagmus and
vertigo in 46.7% of the patients when applied only once, in 80%
of patients when applied twice, and in 93.3% of the patients when
applied three times.
Recently, Yacovino et al (2009) have reported the application of
a different manoeuvre in a small number of eight patients who presented with ASC BPPV and five additional patients who acquired
ASC BPPV following Epleys manoeuvre for the treatment of posterior canal BPPV. According to this manoeuvre, the patient moves
608
In this case the D-H test is performed contralaterally to the lesion and
the uppermost ear is the involved ASC. The torsional component of
the nystagmus is beating toward the involved uppermost ear (apogeotropic), but is increased with gaze deviation toward the healthy
lowermost ear (Korres et al, 2006; Brandt, 2003). By completing
the D-H to the contralateral ear of an affected ASC the pressure
against the cupula and the respective displacement are larger first
because angular acceleration and gravity are both in the direction
of the channel and act synergically to displace otoconia (Bertholon
et al, 2002, Korres et al, 2008).
Korres/Riga/Sandris/Danielides/Sismanis
609
Table 1. History and therapeutic outcome in the population of this study after the application of the manoeuvre proposed by the authors.
Previous manoeuvres manoeuvres that had already been performed unsuccessfully in another medical center. Canal conversion otoconia
being transferred in another semi-circular canal as a result of the proposed repositioning manoeuvre. (-): patient free from symptoms and
clinical findings.
Duration of
symptoms
Previous
manoeuvres
1
2
3
1 week
1 month
1 month
None
Reverse Epley
None
1 month
None
4 months
None
Patients
Canal conversion
(-)
No
No
No
(-)
No
No
In ASC canalithiasis, the nystagmus may be present or more pronounced when the patient is placed (1) with the affected ear uppermost in the D-H examination, (2) with the affected ear lowermost
in the D-H examination, or (3) with head-straight neck hyperextension. The variable laterality of clinical findings in the D-H
examination and head hanging position may represent slight differences in the diameter of the common crus, the position of any obstructions within the membranous duct (Bertholon et al, 2002; Crevits,
2004; Schratzenstaller et al, 2005), or the anatomical positions of
the semicircular canals (Schratzenstaller et al, 2005; Korres et al,
2008). Interestingly, the ASC canalithiasis seems to resolve by the
use of an analogous variety of repositioning manoeuvres, where
the patient may be placed with the affected ear uppermost, lowermost or at neck hyper-extension. After an analysis of the different
combinations of the gravitational forces components amplified in
each manoeuvre, the use of the clinical findings for the selection
610
Discussion
Conclusions
ASC BPPV presents with a variety of clinical manifestations during the D-H examination, which may be attributed to a respective diversity in the orientation of the obstructions within the duct,
the anatomy of the semicircular canals, or even the differences in
the degree of head extension during testing. The canalith repositioning manoeuvres proposed for the treatment of ASC BPPV are
the reverse Epley, the modified Epley, the manoeuvre proposed
by Rahko (2002), by Kim et al (2005), by Yacovino et al (2009),
and a novel manoeuvre described by the authors of the present
study. Similarly to the variety of clinical findings, the repositioning
manoeuvres also seem to use respectively different routes in order
to achieve the movement of otoconia toward the utricle. Although
the orientation of the ASC strongly facilitates the whole procedure
in all cases, this correspondence could possibly indicate that the
clinical findings may be used as guidance for the selection of the
most effective therapeutical manoeuvre. However, further studies
are required before establishing any clinical significance for the
choice of the repositioning manoeuvres according to the clinical
findings of the D-H examination.
Acknowledgements
The authors thank Mrs Athanasia Cheli for the drawings used in the
upper frames of the figures.
Declaration of interest: The authors report no conflicts of interest.
The authors alone are responsible for the content and writing of the
paper.
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