Otology & Neurotology 35:1621Y1625 Ó 2014, Otology & Neurotology, Inc.

A Simple Algorithm for Treating Horizontal Benign Paroxysmal Positional Vertigo *Li-Chen Chu, *†Cheng-Chien Yang, *Hsen-Tien Tsai, and *†‡Hung-Ching Lin *Department of Otolaryngology, Mackay Memorial Hospital; ÞDepartment of Audiology and Speech Language Pathology, and þDepartment of Medicine, Mackay Medical College, Taipei, Taiwan, Republic of China

Objective: Horizontal benign paroxysmal positional vertigo (H-BPPV) is more difficult to successfully treat than posterior benign paroxysmal positional vertigo (P-BPPV) because of the diverse mechanisms required. We developed a simple, rapid, and effective treatment algorithm for treating all subtypes of H-BPPV in an ear, nose, and throat (ENT) outpatient department. Materials and Methods: Four hundred ninety patients with BPPV receiving outpatient treatment at Mackay Memorial Hospital were investigated. Among the 490 patients, 86 (17.6%; 86/490) were diagnosed as having H-BPPV variants using the McClureYPagnini test. Fifty-four patients were female, and 32 were male; they ranged in age from 18 to 92 years (mean age, 56.2 yr). Results: Among the 86 H-BPPV patients, 74.4% (64/86) were hypothesized to have canalithiasis, 20.9% (18/86) were hypothesized to have cupulolithiasis-utricle type (Cup-U), and 4.7% (4/86) were hypothesized to have the cupulolithiasis-cupula type (Cup-C).

The primary treatment maneuver was the forced prolonged position (FPP). For 3 patients exhibiting refractory symptoms, we introduced the Gufoni maneuver. The total average success rate of treatment was 96%. Conclusion: We concluded that for H-BPPV patients with initial geotropic nystagmus, the FPP alone yielded an excellent treatment-control rate, and the barbecue-rotation maneuver was unnecessary. However, observing the nystagmus transformation of apogeotropic patients was necessary before administering treatment. For cupulolithiasis patients with the apogeotropic variant who did not respond to FPP treatment alone, we determined that the Gufoni maneuver was necessary as well. Key Words: CanalithiathisVCupulolithiasisVHorizontal benign paroxysmal positional vertigoVForced prolonged position maneuver. Otol Neurotol 35:1621Y1625, 2014.

Inner-ear related peripheral vertigo is a common complaint of patients receiving treatment in ear, nose, and throat (ENT) outpatient departments. The most frequent type of peripheral vertigo is benign paroxysmal positional vertigo (BPPV), which comprises 17% of all peripheral vertigo cases (1). BPPV can be divided into several subtypes based on which, and how many, semicircular canals are involved. Posterior canal BPPV (P-BPPV) accounts for most BPPV cases and can be diagnosed and treated using a simple and effective method, the Epley maneuver (2). Horizontal canal BPPV (H-BPPV) is relatively rare, with an incidence ranging from 5% (3,4) to 30% (5). H-BPPV is characterized by bidirectional horizontal nystagmus, and the strongest rapid phase is directed toward the affected side. H-BPPV is often related to rotatory head movements performed in a supine position. Compared with P-BPPV, H-BPPV has a longer

latency period and is often accompanied by more intense vertigo and severe neurovegetative symptoms. However, H-BPPV did not appear in the literature until the mid-1980s. McClure first reported 7 cases in 1985 (6), followed by Pagnini et al. in 1989 (7). Numerous cases have been reported since the 1990. Several hypotheses that have been proposed to explain the exact mechanism by which H-BPPV occurs. H-BPPV has recently been reported to exhibit 3 clinical manifestations. The first type, which accounts for 61% to 81.9% of all H-BPPV cases (8,9), is characterized by strong geotropic nystagmus toward the undermost ear. When the patient rolls to the opposite side, a weak geotropic nystagmus from the uppermost side occurs. The second type is an apogeotropic variant, which is characterized by bilateral apogeotropic nystagmus when the patient rolls to each side and is typically stronger when the pathologic side is uppermost. Similar at onset to the second type, the third type begins with bilateral apogeotropic nystagmus on both sides but shifts to geotropic nystagmus after a certain period, regardless of whether further physical maneuvers are performed (8,9). However, another form of nystagmus occurs when geotropic nystagmus transforms into an

Address correspondence and reprint requests to Hung-Ching Lin, M.D., (M.Sc.) Department of Otolaryngology, Mackay Memorial Hospital, No. 92, Chung-shan N Road, Sec. 2, Taipei 104, Taiwan, Republic of China; E-mail: [email protected] The authors disclose no conflicts of interest.


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apogeotropic form, although reports of this form are extremely rare (10). Canalithiasis theory adequately explains the geotropic nystagmus of H-BPPV. The displacement of otoconia debris within the horizontal canal causes an endolymphatic flow because of gravity or angular acceleration, either toward or away from the cupula, leading to excitation or inhibition, and strongly or weakly developed nystagmus. Ewald’s second law illustrates this condition, in which an excitatory stimulus causes greater nystagmus than do inhibitory signals. Cupulolithiasis explains the apogeotropic nystagmus in H-BPPV. The otoconia debris adheres to the cupula, transforming it into a gravitysensitive organ. When the head is rotated, the ‘‘heavy’’ cupula is deflected by gravity, creating either ampullopetal or ampullofugal stimulation, and consequently strong or weak apogeotropic nystagmus develops. The treatment modality for H-BPPV varies widely. Barbecue (BBQ) rotation and the forced prolonged position (FPP) are among the most frequently used maneuvers and are performed separately or simultaneously, with a variable control rate from 73% to 90% (8,11,12). However, a simple, effective method yielding a high success rate does not exist. We developed a simple, rapid, and effective treatment algorithm for all subtypes of H-BPPV received in ENT outpatient department and compared our results with those reported in previous studies. We also explored the possible mechanism underlying difficult variable cases.

MATERIALS AND METHODS From November 2008 to August 2011, we retrospectively reviewed 490 patients with BPPV in the outpatient department of the Mackay Memorial Hospital. Among the 490 patients, 86 (17.6%; 86/490) patients were diagnosed with H-BPPV variants using the supine roll test (McClureYPagnini test) in which the patient lies in a supine position with the head elevated to 30 degrees and subsequently rolls rapidly to the left and right to facilitate the observation of nystagmus. The study included 54 female and 32 male patients, ranging in age from 18 to 92 years, with a mean age of 56.2 years. Sixty-four patients were identified as having geotropic nystagmus, and the remaining 22 were identified as having apogeotropic nystagmus. All the patients were treated with the FPP maneuver by lying on the weaker nystagmus side for 8 to 12 hours at home for several days. Most

FIG. 1.

of the patients were advised to conduct this maneuver during sleeping hours to avoid interference with daily activities. All 86 patients received regular weekly follow-ups until a complete resolution was achieved, which was defined as the absence of vertigo for at least 1 month after the final treatment.

RESULTS We analyzed the treatment outcome of the 86 H-BPPV patients (Fig. 1). In 75.6% (65/86) of the patients, the vertigo symptoms resolved after the FPP treatment; 66.2% (43/65) of those patients were symptom free in the first week, 20% (13/65) in the second week, and 13.8% (9/65) after 3 weeks or longer. The remaining 13.9% (12/86) of the patients exhibited a transformation from the horizontal canal to the posterior canal after the FPP treatment and were treated successfully using the Epley maneuver. The remaining 3.5% (3/86) of the patients returned to the outpatient department because of vertigo recurrence 6 months later, and 7% (6/86) of the patients discontinued participation in the follow-up. The average success rate of treatment was 96% (65 þ 12/86 j 6). We analyzed the various mechanisms exhibited in the 86 H-BPPV patients (Fig. 2) and hypothesized that 74.4% (64/86) of them had canalithiasis and 25.6% (22/86) had cupulolithiasis. Among the 64 patients hypothesized as having canalithiasis, 73.4% (47/64) were successfully treated with the FPP maneuver. Among the remaining 26.6% (17/64) patients with canal-type H-BPPV that failed FPP, 17.2% (11/64) exhibited a transformation to the P-BPPV type, 7.8% (5/64) discontinued participation in the follow-up, and 1.6% (1/64) experienced vertigo recurrence. Among the 22 patients hypothesized as having cupulolithiasis, 4 patients experienced a transformation from cupulolithiasis to canalithiasis after FPP therapy and became symptom free. These 4 patients were hypothesized as having the cupulolithiasis-canal type (Cup-C), whereas the remaining 18 patients were hypothesized as having the cupulolithiasis-utricle type (Cup-U). The Chiou et al. hypothesis (13) states that otoconia attached to the canal side of the cupula drops into the horizontal canal after the FPP treatment; we adopted this hypothesis to explain our observations on the transformation of the aforementioned 4 Cup-C patients (Fig. 3) to canalithiasis

Distribution chart of treatment results for 86 H-BPPV.

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FIG. 2. Distribution of treatment outcome according to different mechanisms. HC canal indicates horizontal canal type; HC Cup-U, horizontal canal cupula-utricle; HC Cup-C, horizontal canal cupula-canal.

(13). The remaining 18 cupulolithiasis patients without nystagmus transformation were hypothesized to have otoconia attached to the utricle side (Fig. 3). Among the 77.8% (14/18) of the 18 Cup-U patients, 11 patients were successfully treated with the FPP, and 3 patients were treated with other combined maneuvers. We introduced the Gufoni maneuver (14) to treat these 3 patients at home because no noticeable effect of prolonged FPP treatment was observed (Fig. 4). The Gufoni maneuver is conducted using an exercise cycle in which the patient initially sits in a neutral position and then moves to the pathologic side with the face turned 45 degrees facing the ground. The patient subsequently sits up and repeats another cycle. Among the rest (4/18) of Cup-U patients, 5.6% (1/18) discontinued participation in the follow-up, 5.6% (1/18) exhibited a transformation to the P-BPPV type, and the remaining 11.1% (2/18) experienced vertigo recurrence (Fig. 2).

DISCUSSION Previous studies have been in consensus that the pathophysiology of geotropic nystagmus in H-BPPV is explained by canalithiasis. Several physical-rehabilitation maneuvers have been suggested for repositioning canalithiasis, including the BBQ rotation, which involves rotating the head from 180 to 360 degrees (15,16), the FPP maneuver (17), the Gufoni maneuver, the Vannucchi-Asprella maneuver, and the Semont maneuver (18). The BBQ rotation and FFP maneuvers are among the most frequently used maneuvers and are performed either separately or simultaneously, with a satisfactory control rate as high as 90% (8,11,12). The FPP has been verified as a highly successful maneuver for treating geotropic variants that is well tolerated by patients (9,17). However, the BBQ rotation maneuver instantly relieves vertigo if the patient can tolerate the rolling movement it involves. However, this movement is often unsuitable for the elderly and is contraindicated for those with spinal problems or severe neurovegetative symptoms. Casani et al. (8) combined FPP and the BBQ-rotation maneuver

to achieve a control rate (90%) similar to that achieved using the Gufoni maneuver (90%) (14,18). However, methods used to treat the apogeotropic variant of H-BPPV produce relatively unsatisfactory results. Cupulolithiasis is generally regarded as a mechanism of apogeotropic nystagmus. The cupula becomes a gravitysensitive organ when otoconia are attached to it, which causes inhibitory ampullofugal deflection when the affected side is turned down. Subsequently, a weaker horizontal nystagmus beating away from the pathologic side is observed, whereas a stronger apogeotropic nystagmus toward the pathologic side is observable when turning to the opposite side (affected side up), because of the ampullopetal deflection of the cupula. Apogeotropic nystagmus exhibits a transformation in the eye-beating direction in certain cases, changing from the apogeotropic to geotropic form following various physical maneuvers. This transformation occurs with a frequency that has been reported to vary from 18.2% to 61.9% (8,9,13). Canalithiasis of the short arm of the horizontal semicircular canal, rather than cupulolithiasis, is proposed to contribute to this direction-changing nystagmus (8,9,18). Canalithiasis of the short arm of the horizontal semicircular canal, which is near the ampulla, creates a similar effect to that of

FIG. 3. Diagram of canalithiasis, Cup-C (cupula-canal), and Cup-U (cupula-utricle) according to the position of otoconia in relation to the utricle. Otology & Neurotology, Vol. 35, No. 9, 2014

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FIG. 4. Treatment modality flow chart for H-BPPV. FPP indicates forced prolonged position; Cup-C type, cupulolithiasis-canal type; Cup-U type, cupulolithiasis-utricle type.

cupulolithiasis, thereby leading to an ampullofugal flow and a subsequently weak apogeotropic nystagmus. After repeating the ‘‘head-turning maneuver,’’ or when the affected side is maintained in the downward position, otoconia near the short arm might disperse or migrate to the posterior arm and become canalithiasis, which explains how apogeotropic nystagmus transforms to a geotropic form. Alternatively, Chiou et al. (13) mentioned that horizontal canal BPPV can be categorized as either canalithiasis or cupulolithiasis and that cupulolithiasis can be further subdivided into canal-sided (Cup-C) and utricle-sided (Cup-U), depending on the side to which the otoconia adheres (13) (Fig. 3). Regarding the transformation of nystagmus, the heavy material, or otoconia, which adheres to the canal side of the cupula, may fall into the horizontal canal because of gravity or angular acceleration and become canalithiasis after physical rehabilitation using the FPP or the Lempert BBQ maneuver are performed, thereby changing the nystagmus direction. This theory is similar to the short-arm canalithiasis hypothesis, which considers the position of otoconia. Following a successful transformation from apogeotropic to geotropic nystagmus, the BBQ or FPP maneuver was used for treating canalithiasis. However, Chiou et al. (13) suggested a single therapy of FPP for all H-BPPV patients in which they are instructed to lie on the weaker side of the nystagmus. The otoconia may fall back to the utricle because of gravity in geotropic types of H-BPPV. Lying on the weak side in apogeotropic types of H-BPPV means the affected side is facing downward and the canal-sided otoconia can thus detach from the cupula to the canal, which can be further treated as canalithiasis. Chiou et al. also reported that utricle-sided otoconia can be successfully dispersed using the same strategy. Based on his theory, the strong side of the apogeotropic nystagmus

may be attributed to the ipsilateral Cup-U or contralateral Cup-C, which are both positioned on the cupula and create the greatest deviation caused by gravity. Therefore, assuming a simple FPP toward the opposite direction can easily detach both types of otoconia, transforming the contralateral Cup-C to canalithiasis and resolving the ipsilateral Cup-U. However, a slight difference exists between Chiou and others, in that Chiou indicated that the deviation of the cupula from the ipsilateral Cup-U should lead to inhibition rather than a strong stimulation. Whether gravity or the direction of deflection determines vestibular stimulation remains controversial. We adopted the treatment protocol using FPP by Chiou et al. (13) and instructed patients to lie on the weaker side of the nystagmus. However, the relief of otoconia on the utricle side (Cup-U) when the FPP is toward the pathologic side is not easily understood. Otoconia might disperse over time rather than by gravity. Several of the study patients reported that they often ‘‘accidentally’’ rolled their heads to the wrong side when practicing the FPP maneuver at home during the night. This unexpected head movement might disperse otoconia. We also observed that Cup-U patients typically could not tolerate intense vertigo when they were forced to lie on their healthy side to treat otoconia on the utricle side. Although not all Cup-U patients were successfully treated, a success rate of 88% (14 þ 1/18 j 1) was nevertheless achieved. Among the Cup-U patients, 3 patients were unresponsive to FPP after 5 weeks. We employed a headshaking maneuver to treat the 3 patients during the outpatient follow-up to detach the firmly attached otoconia, which was unsuccessful. The patients were also instructed on how to perform the Gufoni maneuver at home. A substantially lower percentage of patients in this study (4.6%; 4/86) and in that of Chiou et al. (11.3%) had

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ALGORITHM FOR TREATING H-BPPV the Cup-C variant, compared with results reported by Nuti et al. (61.9%), Casani et al. (64%), and Asprella et al. (60%) (8,9,18). We did not perform a procedure to release otoconia attached to the cupula (or near it, as proposed by the short-arm theory), thereby leading to the low percentage of this variant and speculated that the true incidence of the Cup-C variant should be higher in the results. We eventually obtained a successful treatment rate of 100%, similar to Chiou et al. (13) and Nuti et al. (10). The advantage of the protocol used in this study is that it does not require substantial rehabilitation procedures, which might cause intolerable neurovegetative symptoms. Furthermore, requiring patients to make repeated outpatient department visits poses a risk of physical injury. The side of H-BPPV that is pathologically affected must be defined before a treatment modality is selected; otherwise, inappropriate physical maneuvers might push otoconia in the wrong direction and exacerbate symptoms. Sometimes, it is difficult to detect nystagmus or its direction with the naked eye. Asprella et al. (18) applied used Frenzel glasses or videonystagmography (VNG) to more effectively observe nystagmus. In this study, the direction and intensity of nystagmus was ambiguous in certain cases, which complicated identification. Therefore, we determined patients’ affected side based on their subjective complaints. Despite the high success rate (90%) reported by Casani et al., who combined the BBQ and FPP maneuvers, we seldom treated the study patients using the BBQ maneuver because we previously observed that most of them complained of vigorous vertigo and severe vomiting when performing the BBQ procedure in the outpatient department. Asprella et al. proposed a stepwise ‘‘strategy of the minimum stimulus’’ for treating H-BPPV, with a high success rate of 98% (18,19). Both geotropic and apogeotropic forms were initially treated using the Vannucchi-Asprella maneuver. For refractory cases, they suggested combining various maneuvers (such as the Vannucchi-Asprella and Lempert maneuvers, or the Gufoni and Lempert maneuvers) and using VNG to observe the nystagmus progression and adjust the maneuver accordingly. Despite the impressive cure rate of 98% reported by Asprella, the method they used is not as simple treatment as the FPP maneuver. In this study, a control rate of 96% was obtained by first applying the FPP maneuver, then applying the Gufoni maneuver. The proposed treatment algorithm (Fig. 4) is simple, effective, and appropriate for treating all subtypes of H-BPPV and can be easily deployed by busy outpatient departments. CONCLUSION We believe that successful resolution can be achieved only if an H-BBV patient is first determined to have canalithiasis or cupulolithiasis before further treatment is conducted. We concluded that for H-BPPV patients with


initial geotropic nystagmus, using the FPP maneuver alone, without the BBQ maneuver, was effective. However, for patients with apogeotropic nystagmus, the initial transformation of nystagmus must be observed before further treatment. For most patients with apogeotropic nystagmus, FPP is effective. However, we determined that adding the Gufoni maneuver to the treatment of patients with apogeotropic nystagmus who did not respond to FPP treatment alone is necessary. REFERENCES 1. Katsarkas A. Benign paroxysmal positional vertigo (BPPV): idiopathic versus post-traumatic. Acta Otolaryngol 1999;119(7):745Y9. 2. Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399Y404. 3. Cakir BO, Ercan I, Cakir ZA, et al. What is the true incidence of horizontal semicircular canal benign paroxysmal positional vertigo? Otolaryngol Head Neck Surg 2006;134:451Y4. 4. Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV) CMAJ 2003;169(7): 681Y93. 5. Uno A, Moriwaki K, Kato T, Nagai M, Sakata Y. Clinical features of benign paroxysmal positional vertigo. Nippon Jibiinkoka Gakkai Kaiho 2001;104:9Y16. 6. De la Meilleure G, Dehaene I, Depondt M, et al. Benign paroxysmal positional vertigo of the horizontal canal. J Neurol Neurosurg Psychiatry 1996;60:68Y71. 7. Steddin S, Brand T. Horizontal canal benign paroxysmal positioning vertigo (h-BPPV): transition of canalolithiasis to cupulolithiasis. Ann Neurol 1996;40:918Y22. 8. Casani AP, Vannucci G, Fattori B, et al. The treatment of horizontal canal positional vertigo: our experience in 66 cases. Laryngoscope 2002;112:172Y8. 9. Nuti D, Agus G, Barbieri MT, et al. The management of horizontalcanal paroxysmal positional vertigo. Acta Otolaryngol 1998;118: 455Y60. 10. Nuti D, Vannucchi P, Pagnini P. Lateral canal BPPV: which is the affected side? Audiol Med 2005;3:16Y20. 11. Nuti D, Mandala` M, Salerni L. Lateral canal paroxysmal positional vertigo revisited. Ann N Y Acad Sci 2009;1164:316Y23. 12. Fife T. Recognition and management of horizontal canal benign positional vertigo. Am J Otol 1998;19:345Y51. 13. Chiou WY, Lee HL, Tsai SC, et al. A single therapy for all subtypes of horizontal canal positional vertigo. Laryngoscope 2005;115: 1432Y5. 14. Appiani GC, Catania G, Gagliardi M, et al. Repositioning maneuver for the treatment of the apogeotropic variant of horizontal canal benign paroxysmal positional vertigo. Otol Neurotol 2005;26: 257Y60. 15. Lempert T, Tiel-Wilck K. A positional maneuver for treatment of horizontal-canal benign positional vertigo. Laryngoscope 1996;106: 476Y8. 16. Baloh RW, Jacobson K, Honrubia V. Horizontal semicircular canal variant of benign positional vertigo. Neurology 1993;43:2542Y9. 17. Vannucchi P, Giannoni B, Pagnini P. Treatment of horizontal semicircular canal benign paroxysmal positional vertigo. J Vestib Res 1997;7:1Y6. 18. Asprella Libonati G, Gagliardi G, Cifarelli D. ‘‘Step by step’’ treatment of lateral semicircular canal canalolithiasis under video nystagmoscopic examination. Acta Otolaryngol 2003;23:10Y5. 19. Asprella Libonati G. Diagnostic and treatment strategy of lateral semicircular canal canalolithiasis. Acta Otorhinolaryngol Ital 2005;25: 277Y83.

Otology & Neurotology, Vol. 35, No. 9, 2014

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A simple algorithm for treating horizontal benign paroxysmal positional vertigo.

Horizontal benign paroxysmal positional vertigo (H-BPPV) is more difficult to successfully treat than posterior benign paroxysmal positional vertigo (...
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