Comments on Recent Papers Related to BPPV

Timothy C. Hain, MD
Last update: 10/02

The following articles are arranged chronologically.

• Hughes CA, Proctor L. Benign paroxysmal Positional Vertigo. Laryngoscope 1997:107(5) 607-13. In a review of 187 patients, 36 were felt to be secondary to another ear disease. In 151 patients, 34% had a diagnosis of Meniere's disease.
  Comment: Most people estimate that 5% of BPPV is due to Meniere's disease. At this institution (Johns Hopkins), they found a higher percentage. Either we have underestimated the contribution of Meniere's disease to BPPV, or the referral pattern at this institution is different than most.
• Brevern MV, Lempert T, Bronstein AM, Kocen R. Selective vestibular damage in neurosarcoidosis. Ann Neurol 1997:42:117-120.
  Comment: This paper reports a single case with apparent bilateral lateral canal vestibular paresis, but preserved vertical canal function and BPPV. This article demonstrates that bilateral vestibular paresis (on ENG) is not incompatible with the diagnosis of BPPV, and also that such patients may have preserved vertical canal function.
• Welling DB, Parnes LS, O'Brien B, Bakaletz LO, Brackman DE, Hinojosa R. Particulate matter in the posterior semicircular canal. Laryngoscope 107(1):90-4, 1997. Particles were found in 8 out of 26 patients with BPPV at the time of surgery. No particles were found in 73 patients without BPPV.
• Dunniway HM, Welling DB. Intracranial tumors mimicking benign paroxysmal positional vertigo. Otolaryngol HNS, 1998:118:429-36. These authors report five patients with intracranial conditions mimicking BPPV. They recommend MRI imaging in individuals who do not respond to particle repositioning done twice or who have associated auditory or neurologic symptoms.
  Comment: This is reasonable. Because BPPV is so common, it seems possible that some of these patients may have had both BPPV and unrelated intracranial lesions.
• Vannucchi P, Giannoni B, Pagnini P. Treatment of horizontal canal benign paroxysmal positional vertigo. J. Vest Res. 7(1):-6, 1997. These authors treated lateral canal BPPV by having patients lie on one side with the "healthy" ear down for 12 hours. They reported a cure within three days in 74% of the patients. No treatment resulted in cure in only 24% of the patients.
  Comment: It is difficult to understand why this procedure should work this well, as debris on the ampullary end of the lateral canal would not be seem likely to move by itself up and around the canal. However, sleeping healthy ear down overnight would seem like a reasonable procedure after a "log roll" maneuver.
• Furman JM, Cass SP, Briggs BC. Treatment of benign positional vertigo using heels-over-head rotation. Ann ORL 1998 107(12) 1046-53. A device is described that rotates subjects through 360 degrees to treat BPPV.
  Comment: This is an effective procedure; it also provides additional proof for the canalithiasis hypothesis for the mechanism of classic BPPV.
• Zucca G, Valli AS, Valli P, Perin P, Mira E. Why do benign paroxysmal positional vertigo episodes recover spontaneously? J. Vest Res, 8, 4, 325-329, 1998. These authors suggest that otoconia dissolve in endolymph within about 20 hours, and suggest that this is the reason for spontaneous recovery of BPPV. They do not mention the "dark cell" theory of otoconial resolution. They speculate that lack of spontaneous recovery might be related to increased calcium levels in the endolymph, trapping of otoconia, or ongoing production of loose otoconia.
  Comment: This paper is a useful addition to the literature. The role of the dark cells and the explanation for lack of spontaneous recovery remain obscure.
• Dornhoffer JL, Colvin GB. Benign paroxysmal positional vertigo and canalith repositioning: clinical correlations. Am J Otol 2000 Mar;21(2):230-3. In 52 patients, CRP without use of vibration resulted in 66% cure initially, and eventually 99% cure rate with multiple treatments.
  Comment: This paper suggests vibration is not necessary for good results.
• O'Reilly RC, Elford B, Slater R. Effectiveness of the particle repositioning maneuver in subtypes of benign paroxysmal positional vertigo. Laryngoscope 110:1385-1388, 2000. In 71 patients, the canalith repositioning maneuver was very effective in both primary and secondary BPPV.
  Comment: Another paper that supports CRP effectiveness.
• Ruckenstein MJ. Therapeutic efficacy of the Epley canalith repositioning maneuver. Laryngoscope 2001 Jun;111(6):940-5.
  Comment: Another paper that supports CRP effectiveness. In this study of about 100 patients, nearly all received immediate resolution. Only 4% failed after four treatments.
• Tirelli G, D'Orlando E, Giacomarra V, Russolo M. Benign positional vertigo without detectable nystagmus. Laryngoscope 2001 Jun;111(6):1053-6 . In this paper it is suggested that the CRP is effective even without a diagnosis of BPPV.
  Comment: This paper could suggest, albeit indirectly, that the CRP might be a placebo maneuver, or that improvement might be in part related to the passage of time (see Zucca et al, above) rather than the CRP procedure, per se. This is probably correct -- additional controlled studies are needed.
• Casani, A. P., G. Vannucci, et al. (2002). "The treatment of horizontal canal positional vertigo: our experience in 66 cases." Laryngoscope 112(1): 172-8.
  Comment: This paper suggests that geotrophic nystagmus should be treated with a "barbecue" (logroll) and "forced prolonged posiiton". Patients with bilateral ageotrphic nystagmus should undergo a modified Semont maneuver. This is an interesting paper that would needs confirmation by other workers.
• Yagi, T., M. Morishita, et al. (2001). "Is the pathology of horizontal canal benign paroxysmal positional vertigo really localized in the horizontal semicircular canal?" Acta Otolaryngol 121(8): 930-4.
  Comment: This paper suggests that geotrophic nystagmus is utricular, while ageotrophic nystagmus is from the lateral canal. It seems to us that it is indeed possible that some DCPN is utricular, but so far, the fraction that is utricular vs. lateral canal in origin as well as a practical method of telling one from the other is needed.
• von Brevern, M., A. H. Clarke, et al. (2001). "Continuous vertigo and spontaneous nystagmus due to canalolithiasis of the horizontal canal." Neurology 56(5): 684-6.
  Comment: a case of canalith jam in the lateral canal is presented, which resolved with head-shaking. The author of this page has encountered a patient in whom the "jam" occured due to head-shaking.