• Dizziness Depot discusses hearing-related issues in general but focuses on the inner ear in particular. The inner ear is critical to balance, orientation and visual clarity during movement. As a result, inner ear, or vestibular, problems are the most common cause of dizziness. So, please ask a question or post a comment. Your participation is welcome.

BPPV: Canalithiasis or Cupulolithiasis?

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Benign Paroxysmal Positional Vertigo (BPPV) is typically described by location and type. For example, the most common form of BPPV is posterior canal Canalithiasis. “Posterior” refers to the location (one can also have BPPV in the Horizontal or Anterior Canal), and Canalithiasis refers to the condition of the otoconia (Are they moving freely or stuck on the cupiula?)

In 1969, Dr. Harold Schuknecht first proposed the theory of Cupulolithiasis in which he suggested that BPPV was the result of otoconial debris attached to the cupula of the offending posterior semicircular canal[1]. Epley (1992) offered an alternative theory of Canalithiasis, which more thoroughly explains the source of the typical signs and symptoms of BPPV[2].

The theory of Canalithiasis proposes that there are free-floating particles (otoconia) that have gravitated from the utricle and collect near the cupula of the posterior canal. When the head is moved into a position that causes the particles to move away from the cupula, the resulting hydrodynamic drag causes cupular deflection (and asymmetric stimulation) resulting in vertigo and nystagmus until the particles come to rest in the now gravitationally dependent section of the canal.

It is likely that both of these conditions exist and treatments have been proposed for both.

 

 

 

Footnotes    (↵ returns to text)
  1. .Schuknecht, H. F. (1969). Cupulolithiasis. Arch Otolaryngol Head Neck Surg, 90, 765–778↵
  2. Epley, J. (1992). The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg, 107(3), 399–404↵

The Epley Maneuver –Observations

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The Epley Maneuver, as described originally by John Epley in1992 (see below) [1], is a bit more complicated than necessary. These are just some personal observations from someone who has done somewhere between 10 to 20,000 Canalith Repositioning Procedures, with well over a 90% one session success rate over the past twenty years.

We have never used any vibratory device, and we don’t worry about specific timing of each head movement. There really is no amount of time that is too long, but you just want to make sure that any moving otoconial debris has stopped moving. About one minute in each position is usually more than enough.

The article “Falling sensation in patients undergoing the Epley maneuver” may give you a sense of comfort when this happens to you. Occasionally, on having the patient sit up in the final position of Canalith Repositioning, they will experience what is known as a “Tumarkin’s Otolith Crisis”. This is more commonly referred to in our office as “totally freaking out”. Sometimes the otoconial debris, on leaving the posterior canal, will directly stimulate the utricle, giving the patient the sense that they are flying out of the chair. They will usually start screaming, waving their arms, and pitch forward or backward with all their strength. This sensation lasts just a few seconds, and is a very strong indicator that the repositioning was successful. If you can get the patient to keep their eyes open during this time period, you will typically see a burst of downbeat nysagmus. We ALWAYS hold the patient in a bear hug for a few seconds when sitting them up into the final position.

There are also occasional patients that simply can not get up and walk out of the room after repositioning. My unproven theory is that the debris may have landed on the utricle of the treated ear. In this case, we will reposition them one more time, but this time the goal is not to remove debris from the posterior canal. It is to dislodge debris from the utricle. Even the most unstable patients will improve if you just let them sit for 10 to 15 minutes after Repositioning.

Epley’s (1992) original description of the CRP is as follows:

1. Preliminary—Identification of offending canal and noted latency and duration of nystagmus response

2. Preparation—Premedication with transdermal scopolamine or diazepam

3. Maneuvers—Commencement of maneuvers, changing head positions when the nystagmus response has ceased. If no nystagmus is appreciated, then an estimate of latency plus duration of previous response (typically “6 to 13 seconds”) dictates when the head is moved to the next position. Complete cycles are performed until there is no nystagmus response.

4. Oscillation—A hand-held oscillator with a frequency of approximately 80 Hz is applied to the mastoid process of the affected side.

5. Follow-up—Patients are advised to keep their head upright for 48 hours following the procedure. The CRP may be repeated weekly until the patient is asymptomatic and no nystagmus is noted in the Dix-Hallpike position (Epley, 1992).

 

 

 

 

 

 

 

 

The Canalith Repositioning Procedure for Benign Paroxysmal Positional Vertigo. Otolaryngology Head and Neck Surgery 1992; Volume 107; 399-404. 2.

 

 

 

 

 

 

Footnotes    (↵ returns to text)
  1. The Canalith Repositioning Procedure for Benign Paroxysmal Positional Vertigo. Otolaryngology Head and Neck Surgery 1992; Volume 107; 399-404. 2↵