Are patients better (or not) when they say so?
The first thing we ask our patients when they return for follow up after undergoing Canalith Repositioning (CRP) is, “Are you better?” Most say “Yes, I am fine.” Some say “No, I am still dizzy.”
So, the second question is, “Are you still spinning when you lie down, roll over, etc?” The majority of this group will clarify that the positional vertigo is gone, but that they have some additional continuing symptom that falls under the vague heading of dizziness. Some of these may involve chronic disequilibrium that has nothing to do with their recently resolved BPPV; however, some patients have lingering BPPV-related symptoms after the episodes of vertigo have been resolved.
Many patients will continue to have milder, vague complaints following successful CRP, and this has been reflected in higher Dizziness Handicap Inventory (DHI) scores. These complaints are typically non-specific and do not include symptoms of continued vertigo, nausea or disequilibrium. These patients often describe a non-specific sensation associated with head movement that we have termed “fleeting disorientation.” Most patients describe this as brief (less than one or two seconds), and most often associated with head movement. The sensation is described as fleeting loss of visual stability or orientation. This may be the result of additional vestibular pathology, or may simply be a residual effect of BPPV.
The AAO-HNS Clinical Practice Guideline for BPPV recommends that patients with persistent symptoms following successful CRP undergo additional vestibular evaluation. There is speculation that this “fleeting disorientation” may be the result of a form of cerebellar clamp in response to the transient, but significant asymmetry associated with repeated episodes of BPPV. We find that this sensation usually resolves through normal activity over one to two weeks, but some patients may be given a short course of home-based VOR exercises in hopes of promoting recalibration of the gain of the VOR. There are no current studies comparing VOR gain pre- and post-CRP.
A second group of patients we see fairly often are those that are convinced they will get dizzy if they lie down on a particular side, so have been avoiding that side for weeks, months, even years. It is important to know when a patient last experienced an episode of positional vertigo, but when they tell you it’s been months or years, and they are still avoiding that position, you know there is an anxiety component involved.