Dizziness and Vertigo _________________________________________________________________________
Lateral Canal BPPV Compared with apogeotropic lc-BPPV, the geotropic form is the best-researched and most clinically responsive form. The most frequently used repositioning approaches in lc-BPPV are [20; 21; 39]: • Gradual rotations around the longitudinal axis of the body toward the nonaffected ear • Lying for 12 hours overnight on the non-affected ear (for geotropic) or on the affected ear (for apogeotropic) • The Gufoni maneuver, which moves the patient from sitting to lying sideways with the head turned downward, holding, and repeating The Gufoni maneuver can effectively treat canalithiasis or cupulolithiasis lc-BPPV and has the advantage of eliminating the need to determine the involved form [39; 145]. An alter- native is to first convert cupulolithiasis of the lateral canal to canalithiasis by shaking the head after bending it 90° forward into the vertical plane [39]. Anterior Canal BPPV The Gufoni maneuver or a reverse Epley maneuver has dem- onstrated symptom resolution in more than 75% of patients with ac-BPPV [146]. A new maneuver, called the short CRP and based on simulation with a biomechanical model, was compared with classic CRP in one analysis [147]. Using a previously published 3-dimensional biomechanical model of the human labyrinths for the study of BPPV, the research- ers analyzed conventional CRP in the treatment of anterior canalithiasis. The expected position of free otoliths near the anterior ampulla of the anterior semicircular duct was fol- lowed while recreating the sequential positions of the CRP. Although standard CRP was effective, certain enhancements (e.g., elimination of position 4 of the standard CRP) were found to increase successful repositioning [147]. Vestibular Suppressant Treatment Routine use of vestibular suppressants is not recommended in BPPV, as they may interfere with central compensation and obscure Dix-Hallpike findings. None are as effective as CRPs and cannot be used as CRP substitutes [15; 21]. In some patients, acute/short-term pharmacotherapy can be indicated. Anxiety and BPPV often co-occur; anxiety levels of patients with panic disorder and agoraphobia diagnosed with BPPV remained significantly elevated 14 days after CRP [148]. Thus, benzodiazepines have a role in patients with significant anxiety or who are too anxious to proceed with CRP [15; 21].
In general, CRPs move the patient through a sequence of head position changes that use gravity to move otolith debris (including the pathologic trigger) out of the affected canal and back into the vestibule [21]. CRPs used in canalithiasis or cupulolithiasis appear similar [21]. These procedures should only be performed after the affected canal is identified by diagnostic positioning techniques. Patients should be informed that dizziness, vertigo, or a sense of falling can develop dur- ing a CRP. Patients who had severe nausea or vomiting with the Dix-Hallpike should receive antiemetics 30 to 60 minutes before the procedure [21; 120]. Posterior Canal BPPV CRP is strongly recommended as initial therapy for pc-BPPV [21]. It has a demonstrated high success rate in improving vertigo and in restoring gait and balance in persons with pc- BPPV [143]. The Epley maneuver is the preferred CRP for pc-BPPV and has more than 20 years of evidential support. Meta-analyses have found that, compared with sham or control groups, the Epley led to significantly greater rates of complete vertigo resolution and conversion from a positive to a nega- tive Dix-Hallpike. After 12 months, the Epley was superior to sham maneuver in conversion to negative Dix-Hallpike and perceived disability [21; 144]. The American Academy of Otolaryngology recommends clinicians should treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure (http://journals.sagepub.com/doi/pdf/ 10.1177/0194599816689667. Last accessed September 30, 2024.) Strength of Recommendation : Strong recommendation (Benefits of the recommended approach clearly exceed the harms and that the quality of the supporting evidence is high) The Semont maneuver uses inertial and gravitational forces to move patients briskly down into a side-lying position and then through a rapid 180° arc. In this manner, the Semont repositions free-floating debris from the posterior canal into the vestibule or breaks off canalith from adherence to the cupula [120]. The Semont and Epley maneuvers are comparably effective in pc-BPPV [21]. With speed of rotation critical for a successful Semont, and adequate neck extension and flexibility required for a successful Epley, patient features such as obesity and neck mobility can guide CRP selection [20]. The Semont is a suggested alternative to the Epley for patients with back problems [120].
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