Northeast Florida Medicine
Vol. 66, No. 1 2015
31
Otolaryngology
Comment:
Benign paroxysmal positional vertigo (BPPV)
is by far the most common cause of vertigo in adults
3,4
. The
vertigo is typically transient and provoked when moving
into a specific provocative position. Diagnosis can usually
be made using the Dix-Hallpike maneuver. Symptoms can
be relieved in the office or at home using a simple Epley
Maneuver (Figure 1). For themajority of cases, BPPVoccurs
spontaneously and in the absence of any other vestibular
disease.
3,4
However, the risk of developing BPPV increases
in the wake of other vestibular disease or head trauma.
5
In this case, bilateral post traumatic canalithiasis went
undetected - likely because the patient did not move
into positions that provoked full vertiginous sensations.
In isolation, BPPV would not typically affect a person’s
ability to stand. The combination of unstable vestibular
input in the setting of prior peripheral neuropathy was the
final “straw” that took away this person’s ability to walk.
The Epley Omniax chair is perhaps a luxury. However,
it has an important role to play in the detection and man-
agement of complex forms of BPPV. It has a particularly
useful role in the treatment of post traumatic BPPV, which
is commonly bilateral. Standard Epley repositionmaneuvers
will clear unilateral BPPV. But if applied to the wrong side,
the maneuver can actually make BPPV worse. In bilateral
BPPV, there is always a “wrong side.” With the Epley
Omniax Chair, head positions can be selected that treat
both ears at the same time – using full body 360 degree
backward rotations. In our experience, this capability cuts
treatment time in half.
Points:
• Consider a BPPV cofactor when vertigo, dizziness
or imbalance persists.
• The Epley Omniax Chair is particularly helpful in
the management of patients with positional vertigo
that is unresponsive to standard Epley Maneuvers,
patients with limited neck range of motion, or
patients with bilateral BPPV.
Video Head Impulse Tests
(vHIT) and Vestibular Evoked
Myogenic Potentials (VEMPs)
Traditional vestibular evaluation (video- or electro-nys-
tagmography; VNG or ENG respectively) has been used in
the vestibular laboratory for more than 50 years. The test
only measures horizontal semicircular canal function and
subsequently misses many forms of vestibulopathy. Two
new tests have emerged that overcome these limitations: the
vestibular evoked myogenic potential (VEMP) and video
Head Impulse Tests (vHIT).
VEMPs reflect small changes in muscle tone that result
from stimulation of the otolith organs.
6
They are recorded
using the same signal averaging methods and equipment as
employed in other types of sensory evoked potential testing.
Instead of recording neural field potentials, they capture
changes in surface EMG potentials over specific muscles.
With an appropriate acoustic stimulus, the otolith organs are
transiently stimulated and evoke a corresponding transient
changes in muscle tone. VEMPs recorded from the sterno-
cleidomastoid muscle (cVEMPs) largely reflect activation
of the saccule, inferior vestibular nerve and portions of the
descending vestibule-spinal pathways. Ocular responses
(oVEMPs), recorded from the inferior oblique and inferior
rectus muscles at the inferior portion of the orbit, reflect
activation of the utricle, superior vestibular nerve and parts
of the ascending vestibular ocular pathways.
7
Figure 1.
Self-treatment (canalith repositioning) of LEFT posterior canal
benign paroxysmal positional vertigo (BPPV). Positions 1 and 2
capture the standard Dix-Hallpike maneuver. When the Dix-
Hallpike maneuver provokes transient vertigo, the likelihood
of BPPV on the side of the head turn is high. Completing
the maneuver by rolling into positions 3 – 5 typically clears
the vertigo. The maneuver (rolling from the affected to the
un-affected side) may need to be performed several times to
achieve optimum results. (Figure Copyright 2014, Mayo Clinic
Foundation for Medical Education and Research.)
Figures used with the permission of Mayo Foundation for
Medical Education and Research, all rights reserved
Start sitting on a bed
and turn your head
45º to the left.
Place a pillow behind
you so that on lying
back it will be under
your shoulders.
Lie back quickly with
shoulders on the pillow
and head reclined onto
the bed. Wait until the
symptoms stop then
add 30 seconds.
Turn your head 90º
to the right (without
raising your head)
and wait until any
symptoms stop, then
add 30 seconds.
Turn your body and
head another 90º to
the right and wait for
symptoms to stop, then
add 30 seconds.
Sit up on the right
side of the bed and
bring your head
back to center with
your chin slightly
tucked. Wait until
symptoms stop, then
add 30 seconds.
Make sure you
feel ready before
standing up.
