John M. Epley

The Canalith Repositioning Procedure: For Treatment of Benign Paroxysmal Positional Vertigo

The Canalith Repositioning Procedure (CRP) is designed to treat benign paroxysmal positional vertigo (BPPV) through induced out-migration of free-moving pathological densities in the endolymph of a semicircular canal, using timed head maneuvers and applied vibration. This article describes the procedure and its rationale, and reports the results in 30 patients who exhibited the classic nystagmus of BPPV with Hallpike maneuvers. CRP obtained timely resolution of the nystagmus and positional vertigo in 100%. Of these, 10% continued to have atypical symptoms, suggesting concomitant pathology; 30% experienced one or more recurrences, but responded well to retreatment with CRP. These results also support an alternative theory that the densities that impart gravity-sensitivity to a semicircular canal in BPPV are free in the canal, rather than attached to the cupula. CRP offers significant advantages over invasive and other noninvasive treatment modalities in current use.

New Dimensions of Benign Paroxysmal Positional Vertigo

Twenty-nine patients who demonstrated the classic nystagmus of benign paroxysmal positional vertigo in the provocative, ear-down position had a high incidence of concurrent symptoms. These included vertigo provoked by arising, bending over, head rotation, linear acceleration, and vertical oscillation. Some have not been reported previously in relation to this syndrome. Elimination of both concurrent and classic symptoms via singular neurectomy in nine patients indicates a common pathophysiologic mechanism, probably involving cupulolithiasis in the posterior semicircular canal. These concurrent symptoms should be considered part of the syndrome.

Cost-Effective Management of bEnign Positional Vertigo Using Canalith Repositioning

OBJECTIVE: The misdiagnosis and inappropriate treatment of benign positional vertigo have resulted in significant costs to the medical system. In the current medical-economic climate, there is an increased emphasis on cost control. Recent studies have shown that the canalith repositioning procedure (CRP) is effective; the next step is to show the impact of CRP in cost-effective management of benign positional vertigo. METHODS: Forty-six of 100 patients who underwent CRP for benign positional vertigo responded to a survey regarding the financial impact of their disease. They were asked to subjectively estimate the sum of all disease-related expenses. Objective substantiation of this number was estimated by tabulating physician data, laboratory data, and failed treatment costs. RESULTS: The subjective figure totaled

BPPV and Variants: Improved Treatment Results with Automated, Nystagmus-Based Repositioning

2684.74 per individual. Summation of the tangible objective figures yielded

Singular neurectomy: hypotympanotomy approach.

2009.63 per patient, corroborating the subjective figure. CONCLUSIONS: Because CRP is a relatively simple procedure that can obviate many wasted expenses in most patients, we believe that it is very cost-effective and should be incorporated into routine practice.

The 360-degree maneuver for treatment of benign positional vertigo.

OBJECTIVE: Although classical benign paroxysmal positional vertigo has generally been resolvable by routine manual repositioning maneuvers, nevertheless resistant cases and variants remain a significant problem. We investigated the efficacy of analyzing and treating positional vertigo with a system that provides unlimited, automated maneuverability of the patient while maintaining constant electronic monitoring of nystagmus. STUDY DESIGN AND SETTING: A power-driven, multi-axial positioning chair combined with ongoing infrared video-oculography was used to manage 986 subjects in a tertiary clinical setting with complaints of positional vertigo. A nystagmus-based strategy and condition-specific protocols were used. RESULTS: Significantly enhanced treatment outcomes were achieved, especially regarding intransigent and variant forms. Pertinent correlations were noted. CONCLUSION: This multi-axial positioning chair combination provided enhanced diagnostic and treatment capabilities for managing positional vertigo, apparently due to improved analytical capability, precision repeatability, and unlimited 360-degree maneuverability. SIGNIFICANCE: This advancement should be considered for tertiary management of complicated labyrinthine lithiasis.

Reflexogenic vertigo treated by tensor tympani transection.

A modified surgical technique is described for singular neurectomy. The hypotympanotomy approach provides greater ease in exposing the singular canal. Delayed round window overhang removal provides decreased risk of round window trauma. Eight cases done by this technique indicated a lower complication rate than any reported transmeatal series. Selection criteria, results, and complications are discussed. The risk of cochlear damage limits singular neurectomy to patients who are severely incapacitated by benign paroxysmal positional vertigo. Compared with vestibular neurectomy, singular neurectomy avoids risks inherent in intracranial procedures, and the vertigo caused by surgical intervention is less pronounced.

Tympanic membrane debridement with the CO2 laser.

Objective: The purpose of this study was to determine whether rotating a patient 360 degrees in the plane of the posterior semicircular canal is effective in treating classic benign paroxysmal positional vertigo. The study also compares the features of the Epley maneuver and the Semont maneuver and correlates them to the 360-degree maneuver. Study Design: A prospective analysis of 31 patients presenting with benign paroxysmal positional vertigo who were treated using the multiaxial positioning device. A questionnaire was administered immediately after each treatment. Setting: The study was carried out in a private practice referral clinic for benign paroxysmal positional vertigo. Patients: Subjects consisted of 31 adults who ranged in age from 44 to 95 years. Intervention: Thirty-one patients were treated using the 360-degree maneuver. A multiaxial positioning device was used to rotate patients completely upside down and back into the starting position in the proper plane. Main Outcome Measures: Subjective improvement scores, tolerability, objective nystagmus observations, and complications were recorded. Results: Subjective improvement rates were 90% after one treatment; 97% were symptom-free and nystagmus-free after a maximum of three treatment sessions. Eighty-seven percent found the procedure quite tolerable from an ergonomic standpoint. Conclusion: The 360-degree maneuver can be effective in treating benign paroxysmal positional vertigo. Its rate of success is comparable to the rate of success of the standard Epley maneuver. On analysis, it is strikingly similar to the Epley and Semont maneuvers.

Electronic Probe for Eustachian Tube Patency and Objective Tinnitus

Two patients complained of severe vertigo following eructation or hiccup. One patient was poststapedectomy; the other had idiopathic cochlear degeneration. The symptoms were reproduced by Henneberts test in the pathologic ear. The tensor tympani was transected in both patients. An endolymphatic sac procedure was performed concomitantly in the second patient. Both patients had immediate relief of symptoms. It is hypothesized that these reflex phenomena, which elicited vertigo, were accompanied by tensor tympani contraction, which resulted in medial movement of the stapes or prothesis, and that this movement was transmitted via adhesions to vestibular endorgans to produce the described symptoms.

Positional vertigo related to semicircular canalithiasis

Precise control of tissue penetration can be provided by the CO2 laser at low power. At 1 W, superficial lesions of the tympanic membrane were successfully extirpated in ten patients. The beam produced immediate delamination and carbonization of the external layer, which usually included the lesion, with no apparent effect on the underlying tissue. This charred layer was easily removed mechanically in a bloodless field. No permanent perforations resulted. Extirpation of canal lesions was less effective.