BPPV: State of the Art in Diagnosis And Treatment

Some experts advocate the use of a mastoid bone oscillator during the repositioning maneuver to assist with freeing trapped octoconia and facilitating their movement through the semicircular canals. A 1995 study by John Li, MD, showed that the use of mastoid vibration during repositioning increased the success rate from 60% (in the nonvibration group) to 92% (in the vibration group).3 The literature since that time has shown mixed results regarding the advantage of adding mastoid bone oscillation.4

Dr. Li believes that using oscillation, with or without a device, can help improve results. Ultimately, it’s a matter of physician preference. He stated, The bottom line is, do you prefer to shake the ketchup or not? Although not mandatory, shaking should work better.

The success of canalith repositioning is measured by the patient’s subjective report of resolution of symptoms and by the physician’s objective observation of the disappearance of nystagmus. The use of infrared goggles and a TV monitor can provide real-time observation of nystagmus as the patient is maneuvered into various positions. The physician can also readily identify changes in the type of nystagmus, which can indicate a change in location of the displaced octoconia, and thus a need to change strategies.

If a rotational nystagmus changes to lateral nystagmus, you know you’ve converted to a horizontal canal problem, said Dr. Li.

Dr. Gianoli added, The use of infrared goggles with a TV monitor greatly improves diagnostic ability and the physician’s ability to target which semicircular canal is affected.

Surgical Intervention

A small percentage of patients may fail noninvasive efforts to correct BPPV or have frequent recurrences of symptoms, requiring repeated procedures. For these patients, surgery may offer the best answer.

Singular neurectomy, or section of the posterior ampullary nerve, has demonstrated high efficacy in resolving vertigo. The surgery, however, is technically difficult, and few surgeons have performed the procedure often enough to have become highly proficient. There is a high risk of sensorineural hearing loss associated with singular neurectomy.

The most common surgical intervention for BPPV is posterior semicircular canal occlusion. The semicircular canal lumen is obstructed with a plug fashioned from bone dust and fibrinogen glue, immobilizing the fluid in the canal. This procedure has shown a high rate of success and is much less technically demanding than the singular neurectomy. The primary risk with posterior semicircular canal occlusion is also hearing loss, but there is a much lower incidence than that associated with singular neurectomy.4

The Epley Omniax

A new treatment is now available through Vesticon, Inc., for individuals with BPPV. John Epley, MD, inventor of the Epley maneuver and principal investigator for Vesticon, has developed a computerized patient positioning apparatus for more effective diagnosis and treatment for patients suffering from vestibular disorders, including BPPV. This apparatus, called the Epley Omniax, can rotate patients through 360 degrees in any plane without their bodies and necks being manipulated and twisted. Because the patient is strapped immobile in the chair, this device can be used to treat patients who may not be amenable to manual manipulation on an examining table, such as the morbidly obese and those with some degree of paralysis or arthritis. The device collects data in real time, including correlating the patient’s spatial orientation with 3D eye movement measurements, and it prints out a report for billing and patient management.