Diagnosis Dan Manajemen Bvvp

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Review

Synthèse

Diagnosis and management of benign paroxysmal

positional vertigo (BPPV)

Lorne S. Parnes, Sumit K. Agrawal, Jason Atlas

Abstract

THERE IS COMPELLING EVIDENCE THAT FREE-FLOATING endolymph part-

!le" n the po"teror "em!r!#lar !anal #nderle mo"t !a"e" o$ %e-n&n

paro'y"mal po"tonal (ert&o )*PPV+, Re!ent patholo&!al $ndn&"

"#&&e"t that the"e part!le" are oto!ona pro%a%ly d"-pla!ed $rom theotolth! mem%rane n the #tr!le, They typ!ally "ettle n the dependent

po"teror !anal and render t "en"t(e to &ra(ty, .ell o(er /01 o$

patent" !an %e "#!!e""$#lly treated 2th a "mple o#tpatent

manoe#(re that mo(e" the part!le" %a!3 nto the #tr!le, .e de"!r%e

the (aro#" te!hn4#e" $or th" manoe#-(re pl#" treatment" $or

#n!ommon (arant" o$ *PPV "#!h a" that o$ the lateral !anal, For the

rare patent 2ho"e *PPV " not re"pon-"(e to the"e manoe#(re" and

ha" "e(ere "ymptom" po"teror !anal o!!l#"on "#r&ery " a "a$e and

h&hly e$$e!t(e pro!ed#re,

CMAJ 5006789/):+;9<8-/6

O$ all the nner ear d"order" that !an !a#"e d==ne""or (ert&o %en&n paro'y"mal po"tonal (ert&o )*PPV+ "%y $ar the mo"t !ommon, In 8 lar&e d==ne"" !ln! *PPV2a" the !a#"e o$ (ert&o n a%o#t 8:1 o$ patent",8 It " a

!ondton that " #"#ally ea"ly da&-no"ed and e(en moremportantly mo"t !a"e" are readly treata%le 2th a "mple

o$$!e-%a"ed pro!ed#re, *>r>ny5 $r"tde"!r%ed the !ondton n 8/58;

The atta!3" only appeared 2hen "he lay on her r&ht "de, .hen "he

dd th" there appeared a "tron& rotatory ny"ta&m#" to the r&ht, The

atta!3 la"ted a%o#t thrty "e!ond" and 2a" a!!ompaned %y (olent

(ert&o and na#"ea, I$ mmedately a$ter the !e""aton o$ the"e

"ymptom" the head 2a" a&an t#rned to the r&ht no at-ta!3

o!!#rred and n order to e(o3e a ne2 atta!3 n th" 2ay the patent

had to le $or "ome tme on her %a!3 or on her le$t "de,

Sn!e th" ntal de"!rpton 2a" 2rtten there ha(e %eenma?or ad(an!e" n the #nder"tandn& o$ th" !ommon

!ondton, In th" paper 2e re(e2 the normal (e"t%#lar

phy"olo&y d"!#"" the pathophy"olo&y and !a#"e" o$ *PPV

and then &o on to d"!#"" da&no"e" o$$!e-%a"ed

mana&ement and $nally "#r&!al mana&ement,

Anatomy and physiology

The (e"t%#lar "y"tem montor" the moton and po"-ton

o$ the head n "pa!e %y dete!tn& an&#lar and lnear

a!!eleraton, The 6 "em!r!#lar !anal" n the nner ear

dete!t an&#lar a!!eleraton

and are po"toned at near

r&ht an&le" to ea!h other

)F&, 8+, Ea!h !anal " $lled

2th endolymph and ha" a

"2elln& at the %a"e termed

the @amp#lla )F&, 5+, The

amp#lla !ontan" the@!#p#la a &elatno#" ma""

2th the "ame den"ty a"

endolymph 2h!h n t#rn "

atta!hed to polar=ed har

!ell", Mo(e-ment o$ the

!#p#la %y endolymph !an

!a#"e ether a "tm-#latory

or an nh%tory re"pon"e

dependn& on the dre!-ton

o$ moton and the part!#lar

"em!r!#lar !anal, It "ho#ld

%e noted that the !#p#la

$orm" an mpermea%le%arrer a!ro"" the l#men o$

the amp#lla there$ore part-

!le" 2thn the "em!r!#lar

!anal may only enter and

e't (a the end 2th no

amp#lla,6

@Amp#llo$#&al re$er" to

mo(ement @a2ay $rom the

amp#lla 2herea"

@amp#llopetal re$er" to

mo(ement @to-2ard the

amp#lla )F&, 6+, In the

"#peror and po"teror "em!r!#lar !anal"

#tr!#lo$#&al de$le!ton o$

the !#p#la " "tm#latory and

#tr!#lopetal de$le!ton "

nh%tory, The !on(er"e "

tr#e $or the lateral

"em!r!#lar !anal,

@Ny"ta&m#" re$er" to the

repeated and rhythm! o"!l-

laton o$ the eye",

Stm#laton o$ the

"em!r!#lar !anal" mo"t

!ommonly !a#"e" @?er3

ny"ta&m#" 2h!h "

!hara!-ter=ed %y a "lo2

pha"e )"lo2 mo(ement n 8

dre!ton+ $ol-lo2ed %y a $a"t

pha"e )rapd ret#rn to the

or&nal po"ton+, The

ny"ta&m#" " named a$ter

the dre!ton o$ the $a"t

pha"e, Ny"ta&m#" !an %e

hor=ontal (ert!al o%l4#e

rota-tory or any !om%naton

thereo$, @Geotrop!ny"ta&m#" re$er" to

ny"ta&m#" %eatn& to2ard

the &ro#nd 2herea"

@apo&eotrop! ny"ta&m#"

re$er" to ny"ta&m#" %eatn&

a2ay $rom the &ro#nd,

“ Canaltha"" de"!r%e"

$ree-$loatn& part!le" 2thn

a "em!r!#lar !anal )F&, B+,

The !on!ept 2a" $r"t

de"!r%ed n 8/:/ %y Hall

R#%y and M!Cl#reB and the

phenomenon 2a" $r"tdemon"trated n ((o %y

Parne" and M!Cl#re n

8//5, @C#p#loltha""

de"!r%e" part!le" adherent

to the !#p#la o$ a

"em!r!#lar !anal )F&, B+,

Th" term 2a" !oned %y

S!h#3ne!ht9: n 8/9/,

Mechanism

*PPV !an %e !a#"ed %yether !analtha"" or !#p#-loltha"" and !antheoret!ally a$$e!t ea!h o$ the 6 "em!r-!#lar !anal"altho#&h "#peror !analn(ol(ement " e'!eed-n&ly rare,



CMA SEPT, 60 50067 89/ ):+ 68

© 2003 Canadian Medical Association or its licensors

Parne" et al

Posterior canal BPPV

The (a"t ma?orty o$ all *PPV !a"e" are o$ the po"teror

!anal (arant, The pathophy"olo&y that !a#"e" mo"t po"te-

ror !anal *PPV !a"e" " tho#&ht to %e !analtha"", Th" "

pro%a%ly %e!a#"e mo"t $ree-$loatn& endolymph de%r" tend"

to &ra(tate to the po"teror !anal %en& the mo"t &ra(ty-

dependent part o$ the (e"t%#lar la%yrnth n %oth the #pr&ht

and "#pne po"ton", On!e de%r" enter" the po"teror !anal

the !#p#lar %arrer at the "horter more de-pendent end o$ the

!anal %lo!3" the e't o$ the de%r", There$ore the de%r"

%e!ome" @trapped and !an only e't at the end 2tho#t the

amp#lla )the common crus+ )F&, B+, A&ra2al and Parne"<

$o#nd o%(o#" $ree-$loatn& en-

dolymph part!le" n 601 o$ ear" operated on $or po"teror !anal *PPV )F&, +,

The me!han"m %y 2h!h !analtha"" !a#"e" ny"ta&m#"

n the po"teror "em!r!#lar !anal 2a" de"!r%ed %y Ep-

ley,/80 Part!le" m#"t a!!#m#late to a @!rt!al ma"" n the

dependent porton o$ the po"teror "em!r!#lar !anal, The!analth ma"" mo(e" to a more dependent po"ton 2hen the

orentaton o$ the "em!r!#lar !anal " mod$ed n the

&ra(tatonal plane, The dra& th#" !reated m#"t o(er!ome the

re""tan!e o$ the endolymph n the "em!r!#lar !anal and the

ela"t!ty o$ the !#p#lar %arrer n order to de$le!t the !#p#la,

The tme ta3en $or th" to o!!#r pl#" the or&-nal nerta o$ the

part!le" e'plan" the laten!y "een d#rn& the D'Hallp3e

manoe#(re 2h!h " de"!r%ed later,

lateral)hor=ontal+

anteror

)"#peror+

!anal

B

B°

C h r i s t i n e K e n n e y

!ig. " Spatial orientation o# the semicircular canals. Note

ho2 the po"teror !anal on 8 "de " n the "ame plane a" the

!ontralateral "#peror !anal, *oth lateral !anal" are n the

"ame plane 60 a%o(e the hor=ontal,

68$ AMC 60 SEPT,50067 89/ ):+

In the head-han&n& po"ton the !analth ma"" 2o#ld

mo(e a2ay $rom the !#p#la to nd#!e amp#llo$#&al

!#p#lar de$le!ton, In the (ert!al !anal" amp#llo$#&al

de$le!ton prod#!e" an e'!tatory re"pon"e, Th" 2o#ld

!a#"e an a%r#pt on"et o$ (ert&o and the typ!al @tor"onal

ny"ta&-m#" n the plane o$ the po"teror !anal, In the le$t

head-han&n& po"ton )le$t po"teror !anal "tm#laton+

the $a"t !omponent o$ the ny"ta&m#" %eat" !lo!32"e a"(e2ed %y the e'amner, Con(er"ely the r&ht head-

han&n& po"ton )r&ht po"teror !anal "tm#laton+ re"#lt"

n a !o#nter-!lo!32"e ny"ta&m#", The"e ny"ta&m#"

pro$le" !orrelate 2th the 3no2n ne#rom#"!#lar path2ay"

that ar"e $rom "tm#laton o$ the po"teror !anal amp#llary

ner(e" n an anmal model,88

Th" ny"ta&m#" " o$ lmted d#raton %e!a#"e the en-

dolymph dra& !ea"e" 2hen the !analth ma"" rea!he" the

lmt o$ de"!ent and the !#p#la ret#rn" to t" ne#tral po"-ton,

@Re(er"al ny"ta&m#" o!!#r" 2hen the patent ret#rn" to the

#pr&ht po"ton7 the ma"" mo(e" n the oppo"te d-re!ton

th#" !reatn& a ny"ta&m#" n the "ame plane %#t the oppo"te

dre!ton, The re"pon"e " $at&#a%le %e!a#"e the part!le"%e!ome d"per"ed alon& the !anal and %e!ome le"" e$$e!t(e

n !reatn& endolymph dra& and !#p#lar de$le!ton,

Lateral (horizontal) canal BPPV

Altho#&h *PPV mo"t !ommonly a$$e!t" the po"teror

"em!r!#lar !anal 8 report "#&&e"t" that #p to 601 o$ *PPV

may %e o$ the hor=ontal !anal (arant,85 In o#r d==-ne""

!ln! the hor=ontal !anal (arant a!!o#nt" $or le"" than 1

o$ o#r *PPV !a"e", Ho2e(er o#r $ndn&" may %e



*en&n paro'y"mal po"tonal (ert&o

%a"ed %y the lon& 2at $or an a""e""ment n o#r !ln! )

month"+ a" t ha" al"o %een o#r e'peren!e that lateral

!anal *PPV re"ol(e" m#!h more 4#!3ly than po"teror

!anal *PPV, The"e o%"er(aton" are #nder"tanda%le

2hen one !on"der" the orentaton" o$ the !anal", The

po"teror !anal han&" n$erorly and ha" t" !#p#lar %arrer at t" "horter more dependent end, Any de%r" entern&

the !anal e""entally %e!ome" trapped 2thn t, In

!ontra"t the lateral !anal "lope" #p and ha" t" !#p#lar

%arrer at the #p-per end, There$ore $ree-$loatn& de%r" n

the lateral !anal 2o#ld tend to $loat %a!3 o#t nto the

#tr!le a" a re"#lt o$ nat#ral head mo(ement",

In lateral !anal !analtha"" part!le" are mo"t o$ten n the

lon& arm o$ the !anal relat(ely $ar $rom the amp#lla, I$ the

patent per$orm" a lateral head t#rn to2ard the a$$e!ted ear

the part!le" 2ll !reate an amp#llopetal endolymph $lo2

2h!h " "tm#latory n the lateral !anal, A &eotrop!

ny"ta&m#" )$a"t pha"e to2ard the &ro#nd+ 2ll %e pre"ent, I$

the patent t#rn" a2ay $rom the a$$e!ted "de the part!le" 2ll

!reate an nh%tory amp#llo$#&al $lo2, Altho#&h the

ny"ta&m#" 2ll %e n the oppo"te dre!ton t 2ll "tll %e a

&eotrop! ny"ta&m#" %e!a#"e the patent " no2 $a!n& the

oppo"te dre!ton, Stm#laton o$ a !anal !reate" a &reater

re"pon"e than the nh%ton o$ a !anal there$ore the dre!-ton o$ head t#rn that !reate" the "tron&e"t re"pon"e ),e,

"tm#latory re"pon"e+ repre"ent" the a$$e!ted "de n &eo-

trop! ny"ta&m#" )Ta%le 8+,

C#p#loltha"" " tho#&ht to play a &reater role n lateral

!anal *PPV than n the po"teror !anal (arant, A" part!le"

are dre!tly adherent to the !#p#la the (ert&o " o$ten n-

ten"e and per""t" 2hle the head " n the pro(o!at(e po"-


"a!!#le

endolymphat! "a!

amp#llae

!ig. $" %sseous

&grey'white( and

membranous &la)ender(

labyrinth o# the le#t

inner ear. Perlymph $ll"

the o""eo#" la%yrnth

e'ternal to themem%rano#" la%yrnth

2herea" endolymph $ll"

the mem%rano#"

la%yrnth,



CMA SEPT, 60 50067 89

Parne" et al

ton, .hen the patentJ" head " t#rned to2ard the a$$e!ted

"de the !#p#la 2ll #nder&o an amp#llo$#&al )nh%tory+

de$le!ton !a#"n& an apo&eotrop! ny"ta&m#", A head

t#rn to the oppo"te "de 2ll !reate an amp#llopetal

)"tm#la-tory+ de$le!ton re"#ltn& n a "tron&er

apo&eotrop! ny"-ta&m#", There$ore t#rnn& a2ay $rom

the a$$e!ted "de 2ll !reate the "tron&e"t re"pon"e )Ta%le

8+, Apo&eotrop! ny"-ta&m#" " pre"ent n a%o#t 5:1 o$

patent"85 2ho ha(e lat-eral !anal *PPV,

*pidemiology

*PPV " the mo"t !ommon d"order o$ the perpheral

(e"t%#lar "y"tem,86 M=#3o"h and !ollea&#e"8B e"tmated the

n!den!e to %e 80,: to 8:,6 per 800 000 per year n apan

altho#&h th" " l3ely to %e an #ndere"tmate %e-!a#"e mo"t

!a"e" o$ *PPV re"ol(e "pontaneo#"ly 2thn month", Se(eral

"t#de" ha(e "#&&e"ted a h&her n!den!e n 2omen8B89 %#tn yo#n&er patent" and tho"e 2th po"t-tra#mat! *PPV the

n!den!e may %e e4#al %et2een men and 2omen,8 The a&e

o$ on"et " mo"t !ommonly %et2een the $$th and "e(enth

de!ade" o$ l$e,8B88: Elderly people are at n!rea"ed r"3 and

a "t#dy o$ an elderly pop#laton #n-der&on& &eratr!

a""e""ment $or non-%alan!e-related !om-plant" $o#nd that

/1 had #nre!o&n=ed *PPV,8< *PPV mo"t o$ten n(ol(e" a

"n&le "em!r!#lar !anal #"#ally po"-

teror %#t may n(ol(e %oth po"teror and lateral !anal"n the "ame nner ear, Po"teror !anal *PPV may!on(ert to lateral !anal *PPV $ollo2n& repo"tonn&manoe#(re", Head tra#ma " the mo"t !ommon !a#"eo$ "m#ltaneo#" %lateral po"teror !anal *PPV,

+auses o# PP-

In mo"t !a"e" *PPV " $o#nd n "olaton andtermed @prmary or @dopath! *PPV, Th" typea!!o#nt" $or a%o#t 01:01 o$ !a"e", The mo"t!ommon !a#"e o$ @"e!ondary” *PPV " head tra#marepre"entn& :18:1 o$ all *PPV !a"e",88 A %lo2 tothe head may !a#"e the re-lea"e o$ n#mero#" oto!onanto the endolymph 2h!h pro%a%ly e'plan" 2hy manyo$ the"e patent" "#$$er $rom %lateral *PPV,8 Vralne#rola%yrntht" or "o-!alled @(e"t%#lar ne#ront"ha" %een mpl!ated n #p to 81 o$ *PPV !a"e",8

MKnreJ" d"ea"e ha" al"o %een "ho2n to %e "tron&ly a"-"o!ated 2th *PPV, There " lar&e (araton n the ltera-t#re

re&ardn& 2hat proporton o$ patent" 2th *PPV al"o ha(e

the da&no"" o$ MKnreJ" d"ea"e, E"tmate" ran&e $rom

0,1 to 681,8/50 Gro"" and !ollea&#e"58 $o#nd that ,1 o$

patent" 2th MKnreJ" d"ea"e had @!ertan po"-teror !anal

*PPV, The !a#"at(e me!han"m " not 2ell #nder"tood %#t

may %e the re"#lt o$ hydrop!ally nd#!ed



po"teror !anal

no

ta

t

or

da

h

e

amp#llopetal

endolymph $lo2nd#!e" #tr!#lopetal

d"pla!ement o$

#tr!le the !#p#la

no

ta

t

or

da

e



amp#llo$#&alendolymph $lo2

nd#!e" #tr!#lo$#&ald"pla!ement o$

#tr!le the !#p#la




!#p#la !#p#la

amp#lla 800 m" amp#lla 800 m"

har !ell" har !ell"

CNVIII CNVIII

de!rea"ed n!rea"edne#ral $rn& ne#ral $rn&

)po"teror !anal+ )po"teror !anal+

!ig. "

Schematic

drawing o# the

physiology o#

the le#t

posterior

semicircular

canal. In the

ma&e on the

r&ht note the

e'!tatory

re"pon"e

)n!rea"ed

ne#ral $rn&+

2th

#tr!#lo$#&al

!#p#lar

d"pla!ement,

The "ame

e'!tatory

re"pon"e 2o#ld

o!!#r n the

"#pe-ror

)anteror+ !anal

2th

#tr!#lo$#&al

!#p#lar

d"pla!ement

2herea" the

oppo"te

)nh%tory+

re"pon"e 2o#ld

o!!#r 2th

#tr!#lo$#&al

!#p#lar

d"pla!ement n

the lateral

!anal, The

"ame r#le"

2o#ld apply to

the ma&e on

the le$t, CNVIII

(e"t%#lar

ner(e m"

mll"e!ond,



68/ AMC6

dama&e to the ma!#la o$ the #tr!le or %y partal

o%"tr#!-ton o$ the mem%rano#" la%yrnth,58

Re!ently m&rane" ha(e %een $o#nd to %e !lo"ely

a""o-!ated 2th *PPV, I"hyama and !ollea&#e"55 and

Lempert and !ollea&#e"56 $o#nd an n!rea"ed n!den!e

o$ m&rane n patent" 2th *PPV and h&her re!#rren!e

rate" o$ *PPV a$ter "#!!e""$#l po"tonn& n patent" 2th

m-&rane, It ha" %een "#&&e"ted that "pa"m o$ the nner

ear ar-tere" may %e a po""%le !a#"at(e me!han"m

%e!a#"e (a-"o"pa"m " 2ell do!#mented n

m&rane",555B

Se!ondary *PPV ha" al"o %een de"!r%ed a$ter nner ear "#r&ery,50559 The !a#"e " tho#&ht to %eln3ed to #tr!#lar dama&e d#rn& the pro!ed#releadn& to the re-lea"e o$ oto!ona,

!#p#la !#p#loltha""

amp#lla

K e n n e y

C h r i s t i n e

!analtha""

!ig. /" Le#t inner ear. Dep!ton o$ !analtha"" o$ the

po"teror !anal and !#p#loltha"" o$ the lateral !anal,


0iagnosis

History

Patent" de"!r%e "#dden "e(ere atta!3" o$ ether hor-

=ontal or (ert!al (ert&o or a !om%naton o$ %oth pre!p-

tated %y !ertan head po"ton" and mo(ement", The mo"t

!ommon mo(ement" n!l#de rolln& o(er n %ed e'tendn&

the ne!3 to loo3 #p and %endn& $or2ard, Patent" !an o$ten

dent$y the a$$e!ted ear %y "tatn& the dre!ton o$ mo(e-

ment that pre!ptate" the ma?orty o$ the atta!3" )e,&, 2hen

rolln& o(er n %ed to the r&ht %#t not the le$t pre!ptate"

d==ne"" th" nd!ate" r&ht ear n(ol(ement+, A "t#dy %y

entala and Pyy33o5: reported that <01 o$ patent" e'per-

en!e a rotatory (ert&o and B:1 e'peren!e a $loatn& "en"a-

ton, The atta!3" o$ (ert&o typ!ally la"t $e2er than 60 "e!-

ond" ho2e(er "ome patent" o(ere"tmate the d#raton %y

"e(eral mn#te", Rea"on" $or th" d"!repan!y may n!l#dethe $ear a""o!ated 2th the nten"e (ert&o alon& 2th the

na#"ea and d"e4#l%r#m that may $ollo2 the atta!3, The

(ert&o atta!3" o!!#r n "pell"7 patent" ha(e "e(eral atta!3"

a 2ee3 )561+ or d#rn& the !o#r"e o$ 8 day )51+,5:

In addton to (ert&o many patent" !omplan o$ l&ht-

headedne"" na#"ea m%alan!e and n "e(ere !a"e"

"en"-t(ty to all dre!ton" o$ head mo(ement, Many patent"

al"o %e!ome e'tremely an'o#" $or 5 man rea"on", Some

$ear that the "ymptom" may repre"ent "ome 3nd o$ "n"ter

#nderlyn& d"order "#!h a" a %ran t#mo#r, For other" the

"ymptom" !an %e "o #n"ettln& that they &o to &reat len&th"

to a(od the part!#lar mo(ement" that %rn& on the (er-t&o,

For th" rea"on "ome may not e(en real=e that the!ondton ha" re"ol(ed a" t "o o$ten doe" o(er tme 2th-o#t

any treatment at all, *PPV !an %e de"!r%ed a" "el$-lmted

re!#rrent or !hron!,

A" the name mple" *PPV " mo"t o$ten a %en&n !ond-ton

ho2e(er n !ertan "t#aton" t may %e!ome dan&ero#", For

e'ample a panter loo3n& #p $rom the top o$ a ladder may

"#ddenly %e!ome (ert&no#" and lo"e h" or her %alan!e

r"3n& a %ad $all, The "ame 2o#ld hold tr#e $or #nder2ater

d(er" 2ho m&ht &et (ery d"orented $rom a!#te (ert&o, Hea(y

ma!hnery operator" "ho#ld #"e &reat !a#ton e"pe-!ally $ ther

?o% n(ol(e" "&n$!ant head mo(ement, Mo"t people !an "a$ely

dr(e ther !ar a" lon& a" they are !are$#l not to tp ther head

%a!3 2hen !he!3n& ther %lnd "pot,

!ig. 1" Se2uential computer3

regenerated photographs

ta4en #rom an intra3operati)e

)ideo o# a #enestrated

posterior semi3circular canal.

Note the "n&le 2hte

!on&lomerate ma"" 2thn the

mem%rano#" d#!t )arro2+ )le$t+,

Note ho2 the ma"" ha"

$ra&mented nto tny part!le"

56 mn#te" later a$ter the

mem-%rano#" d#!t ha" %een

pro%ed )r&ht+,

5able " Lateral &horiontal(

canal PP- 7 side o# origin

and mechanism based upon

direction and intensity o#

nystagmus

Sde o$ or&n and me!han"m o$ *PPV

Apo&eotrop!

Inten"ty o$ ny"ta&m#" ny"ta&m#"

Stron&er on le$t "de R&ht !#p#loltha""

Stron&er on r&ht "de Le$t !#p#loltha"

Note; *PPV %en&n paro'y"mal

po"tonal (ert&o, Lateral !anal *PPV

"de o$ or&n and me!han"m are

%a"ed #pon the dre!ton and nten"tyo$ ny"ta&m#" n the 5 lateral head

po"ton",

CMA SEPT, 60 50067 89/):+ 681



Parne" et al

Altho#&h 01:01 o$ *PPV " dopath! )2th no tent 2ll de"!r%e $eeln& (ert&no#" the nten"ty o$ 2h!hdent$a%le !a#"e+ a h"tory "ho#ld %e ta3en re&ardn& po"- parallel" the ny"ta&m#" re"pon"e, It "ho#ld %e empha"=ed

"%le "e!ondary !a#"e" o$ *PPV, The"e n!l#de head that the 5 po"teror !anal" are te"ted ndependently thetra#ma (ral la%yrntht" or (e"t%#lar r&ht 2th the head t#rned r&ht and the

ne#ront" MKnreJ" d"ea"e m-

+auses o# ,PP-

le$t 2th the head t#rned le$t,

&rane" and otolo&! and nonotolo&! Te"tn& $or lateral !anal *PPV ""#r&ery,

Prmary or dopath! )01:01+done %y layn& the patent "#pne andthen 4#!3ly t#rnn& the patentJ" head

Diagnostic anoe!"resSe!ondary )60101+

)and %ody+ laterally to2ard the "de %e- Head tra#ma ):18:1+n& te"ted, A p#rely hor=ontal ny"ta&- Vral la%yrntht" )81+

The #"e o$ the D'Hallp3e ma- m#" o!!#r" that " &eotrop! )$a"t !om- MKnreJ" d"ea"e )1+noe#(re to da&no"e po"teror !anal M&rane" ) 1+ ponent to2ard the lo2ermo"t ear+ n*PPV 2a" $r"t de"!r%ed n 8/C5,5< A" Inner ear "#r&ery ) 81+ the ma?orty o$ !a"e" %#t may %e apo-"ho2n n F&, 9 the patent " ntally &eotrop! )to2ard the #ppermo"t ear+ n"eated n po"ton A and then lo2ered 5:1 o$ !a"e",85 Compared 2th theto po"ton * and the patentJ" eye" are o%"er(ed $or ny"ta&- (ert!alFtor"onal ny"ta&m#" o$ po"teror !anal *PPV th"m#", A$ter the head " lo2ered the typ!al ny"ta&m#" on"et hor=ontal ny"ta&m#" ha" a "horter laten!y "tron&er nten-

ha" a %re$ laten!y )8FC "e!ond"+ and lmted d#raton )typ- "ty 2hle mantann& the te"t po"ton and " le"" prone to

!ally O 60 "e!ond"+, .th the eye" n the md )ne#tral+ po"- $at&#e,5/ *oth "de" are te"ted and the dre!ton o$ ny"ta&-ton the ny"ta&m#" ha" a "l&ht (ert!al !omponent the $a"t m#" !o#pled 2th the dre!ton o$ roll that !a#"e" the &reat-

pha"e o$ 2h!h " #p%eatn&, There " a "tron&er tor"onal e"t ny"ta&m#" nten"ty o$ten dent$e" the a$$e!ted "de and

!omponent the $a"t pha"e o$ 2h!h ha" the "#peror pole o$ the me!han"m )Ta%le 8+,

the eye %eatn& to2ard the a$$e!ted )dependent+ ear, The d- O(erall the h"tory and eye-$ndn&" d#rn& po"tonalre!ton o$ the ny"ta&m#" re(er"e" 2hen the patent " te"tn& are the &old "tandard" $or da&no"n& *PPV, Add-%ro#&ht nto the #pr&ht po"ton and the ny"ta&m#" 2ll $a- tonal te"tn& " not normally ne!e""ary, *e!a#"e ele!trony"-

t&#e 2th repeat te"tn&, Alon& 2th the ny"ta&m#" the pa- ta&mo&raphy )ENG+ doe" not re!ord tor"onal eye mo(e-


!ig. 6" 0i9:allpi4e manoeu)re &right ear(. The patent " "eated and po"toned "o that the patentJ" head 2ll e'tend o(er the top

ed&e o$ the ta%le 2hen "#pne, The head " t#rned B to2ard the ear %en& te"ted )po"ton A+, The patent " 4#!3ly lo2ered nto the

"#pne po"ton 2th the head e'tendn& a%o#t 60 %elo2 the hor=ontal )po"ton *+, The patentJ" head " held n th" po-"ton and the

e'amner o%"er(e" the patentJ" eye" $or ny"ta&m#", In th" !a"e 2th the r&ht "de %en& te"ted the phy"!an "ho#ld e'pe!t to "ee a

$a"t-pha"e !o#nter-!lo!32"e ny"ta&m#", To !omplete the manoe#(re the patent " ret#rned to the "eated po"ton )po"ton A+ and

the eye" are o%"er(ed $or re(er"al ny"ta&m#" n th" !a"e a $a"t-pha"e !lo!32"e ny"ta&m#",



686 AMC 60 SEPT, 50067 89/ ):+




ment" t

add"

lttle to

the

da&no"

" o$ *PPV,

More re-

!ently

n$rared

(deo&ra

phy ha"

allo2ed

$or dre!t

eye o%-

"er(ato

n d#rn&

the

te"tn&manoe#

(re" %#t

6-

dmen"

onal eye

mo(eme

nt

analy""60 " not

!ommon

n

!ln!al

pra!t!e,Rotaton

al-!har

te"tn&

and

po"t#ro&

raphy

ha(e no

role to

play n

th"

d"order,

Ima&n&

2th CT"!annn

& or MRI

"

#nne!e"

"ary

#nle""

there

are

atyp!al

or

#n#"#al

$eat#re"

to the

a""e""ment,

#!$%ecti" e "ers!so$%ecti"eBPPV

A !ertan

"#%"et o$

patent" may

not

demon"trate

the typ-!al

ny"ta&m#"

d#rn& the

D'Hallp3e

manoe#(re

%#t they may

"tll

e'peren!e

the !la""!

(ert&o

d#rn&

po"ton-n&,

Th" ha"

%een termed

@"#%?e!t(e

*PPV and

"e(eral

"t#de" ha(e

$o#nd

repo"tonn&

manoe#(re"

to %e h&hly

e$$e!t(e nth" &ro#p o$

patent",

Hayne" and

!ollea&#e"68

Trell and

!ollea&#e"65

and .eder

and

!ollea&#e"66

$o#nd that

patent" 2th

"#%?e!t(e

*PPV 2ho2ere treated

2th (aro#"

repo"tonn&

manoe#(re"

had

re"pon"e

rate" o$

:91/61

o(erall,

Propo"ed

theore" to

e'plan the

la!3 o$

ny"ta&m#" n

patent" 2th

*PPV d#rn&

the D'

Hallp3e

manoe#(re

n!l#de the

$ollo2n&;

"#%tle

ny"ta&m#"

m""ed %y

the o%"er(er

$at&#ed

ny"ta&m#"

$rom repeat

te"tn& %e-

$ore the

manoe#(re

and a le""

no'o#" $orm

o$ *PPV that

el!t" (ert&o%#t 2th an

nade4#ate

ne#ral "&nal

to "tm#-late

the (e"t%#lo-

o!#lar

path2ay,68

Di&&erenti aldiagnosis

There are(ery $e2

!ondton"

that !an

e(en

remotely re-

"em%le

*PPV, In

MKnreJ"

d"ea"e the

(ert&o

"pell" are

not

pro(o3ed %ypo"ton

!han&e and

they la"t

m#!h lon&er

)60 mn#te"

to "e(eral

ho#r"+,

F#rthermore

there "

a!!om-

panyn&

tnnt#" and

hearn& lo"",



The

(ert&o

n

la%yrnth

-t" or

(e"t%#l

ar

ne#ront

" #"#ally

per""t"

$or day",

The (er-

t&o may

%e

a&&ra(at

ed %y

head

mo(eme

nt" n

any

dre!ton

and

th"

need" to%e

!are$#lly

e'tra!te

d $rom

the

h"tory

"o a" to

not

!on$#"e

t 2th

"pe!$!

po"ton

!han&ee(o3ed

(ert&o,

In

addton

the D'

Hallp3e

te"t

"ho#ld

not

nd#!e

the %#r"t

o$

ny"ta&m#" "een

n *PPV,

Very

rarely

po"teror

$o""a

t#mo#r"

!an

mm!

*PPV

%#t

there

ha(e

%een no

report" n

the lterat#re

o$ a t#mo#r

that ha"

per$e!tly

repl!ated all

o$ the

$eat#re" o$ a

po"t(e D'

Hallp3e

manoe#(re,

A"

mentoned

pre(o#"ly

*PPV !an

%e

"e!ondary

"o a" to

o!!#r

!on!#rrently

2th or "#%-

"e4#ent to

other nner ear or CNS

d"order",

F#rthermore

%en& "o

!ommon

*PPV !an

o$ten %e a

!on!dental

$nd-n& 2th

other

d"order",

;onsurgicalmanagement

The

mana&ement

o$ *PPV ha"

!han&ed

dramat!ally

n the pa"t

50 year" a"

o#r #nder"tandn

& o$ the

!ondton ha"

pro&re""ed,

Tradtonally

patent" 2ere

n"tr#!ted to

a(od

po"ton" that

nd#!ed ther

(ert&o,

Med!aton"

2ere pre-



"!r%ed

$or

"ympto

mat!

rele$

%#t 8

do#%le-

%lnd

"t#dy

"ho2ed

that they

2ere

lar&ely

ne$$e!t

(e,6B

*PPV "

"el$-

lmted

and

mo"t

!a"e"

re"ol(e

2thn 9

month",

A" the

theore"

o$

!#p#lolt

ha""

and

!analth

a""

emer&e

d "e(-

eral

nonn(a

"(e

te!hn4#

e" 2ere

de(elop

ed to

!orre!t

the

patholo&

y

dre!tly,

An

earler

method

#"ed

ha%t#at

on e'-

er!"e"

and

altho#&h

"ome

%ene$t

2a"

a!he(e

d the

e$$e!t 2a"

not lon&-

la"tn& and

the

e'er!"e"

pro(ed to %e

too %#r-

den"ome $or

many

patent",669

Li$erator yanoe!"r e

In 8/<<

Semont and

!ollea&#e"6:

de"!r%ed

the @l%era-

tory

manoe#(re

)F&, :+

%a"ed on

the

!#p#loltha"

" the-ory, It

2a"

%ele(ed

that th"

"ere" o$

rapd

!han&e" o$

head

po"ton

$reeddepo"t"

that 2ere

atta!hed to

the !#p#la,

The

manoe#(re

%e&n" 2th

the patent

n the "ttn&

po"-ton

and the

head t#rned

a2ay $romthe a$$e!ted

"de, The

patent "

then 4#!3ly

p#t nto a

po"ton

lyn& on h"

or her "de

to2ard the

a$$e!ted

"de 2th

h" or her

head t#rned

#p2ard,

A$ter a%o#t

mn#te"

the patent "

4#!3ly

mo(ed %a!3

thro#&h the

"ttn&

po"ton to

the op-

po"te

po"ton

lyn& on h"

or her "de

2th h" or

her head

no2 $a!n&

do2n2ard,

The patent

reman" n

th" "e!ond

po"ton $or

80mn#te"

%e$ore

"lo2ly %en&

%ro#&ht

%a!3 to the

"ttn&

po"ton,In ther

"ere" o$ :88

patent"

Semont and

!ollea&#e"6:

$o#nd an <B1re"pon"e rate

a$ter 8

pro!ed#re

and a /61 re-

"pon"e rate

a$ter a "e!ond

pro!ed#re 8

2ee3 later,

Se(eral other

!a"e "ere"

ha(e had

re"pon"e

rate" o$ 51/01686<6/B0

2th

re!#rren!e

rate" o$ #p to

5/1,68 There

ha" %een no

d$-$eren!e n

e$$!a!y

"ho2n

%et2een the

l%eratory

manoe#(re



and

part!le

repo"ton

n&

manoe#(

re 2h!h

"

de"!r%ed

n the

$ollo2n&

"e!ton

n

random=

ed

"t#de"

%y

Herdman

and

!ollea&#e

"6/ and

Cohen

and

era%e3,B

8 In o#r

opnon

the l%-

0iagnosiso#PP-

H"tory

1• Ro

tatory(er t&o

2• La

"t"60"e!ond"

3• Pr

e!ptate

d %yheadmo(ement"

D'Hallp3emanoe#(r e)po"teror!anal*PPV+

1• *re$

laten!y)8"e!ond"+

2• Lmted

d#raton ) 60"e!ond"+

3• Tor"on

alny"ta&

m#"to2arddo2nmo"t ear

4• Re(er"

al o$ ny"ta&m#"#pon"ttn&

5• Fat&#

a%ltyo$ there"pon

"eLateralhead t#rn")hor=ontal!anal*PPV+

1• Geotro

p!ny"ta&m#"

2

•

A

p

o

&

e

o

t

r

o

p

!

n

y

"t

a

&

m

#

"

S

#

%

?

e

!

t

(

e

*

P

P

V

3• Cla""!

(ert&od#rn&po"to

nn&4• No

ny"t

a&m

#"

"een

repo

"to

nn&

man

oe#(

re"

"tll

e$$e!

t(e

CMA

SEPT, 6050067 89/

):+ 68<

Parne" et al

eratory

manoe#(re "

e$$e!t(e %#t "

!#m%er"ome 2th

el-derly and

o%e"e patent"

and "ho2" no

n!rea"ed e$$!a!y

!ompared 2th

the "mple part!le

repo"tonn&



manoe#(re,

Particlere'ositioning anoe!"re

Altho#&h he

had %een

tea!hn& h"

te!hn4#e $or

many year" t

2a" not #ntl

8//5 that EpleyB5

p#%l"hed h"

$r"t report on the

@!analth

repo"tonn&

pro!ed#re

)CRP+, Th"

h&hly "#!!e""$#l

@Epley

manoe#(re "

per$ormed 2th

the patent"edated,

Me!han!al "3#ll

(%raton " ro#-

tnely #"ed and

the patentJ"

head " mo(ed

"e4#entally

thro#&h

"eparate

po"ton", Epley

po"t#lated that

the pro-!ed#re

ena%led theotolth! de%r" to

mo(e #nder the

n-$l#en!e o$

&ra(ty $rom the

po"teror

"em!r!#lar

!anal nto the

#tr!le, Mo"t

!ln!an" today

are tho#&ht to

#"e a mod-$ed

(er"on o$ the

CRP,One mod$ed

CRP " the

part!le

repo"tonn&

ma-noe#(re

)PRM+ 2h!h " a

6-po"ton

manoe#(re that

elm-

nate" the need

$or "edaton and

ma"tod

(%ratonB6BB )F&,

<+, .th proper

#nder"tandn& o$

nner ear

anatomy and thepathophy"olo&y

o$ *PPV (aro#"

approprately

traned health

pro$e""onal"

n!l#dn& $amly

do!tor" and

phy"otherap"t"

"ho#ld %e a%le

to "#!!e""$#lly

!arry o#t the

PRM n mo"t

"tra&ht$or2ard!a"e", Atyp!al

!a"e" or !a"e"

that do not

re"pond to th"

manoe#(re

"ho#ld %e re-

$erred to a

tertary !are

d==ne"" !ln!,

In the PRM;

1. Pla!e the

patent n a

"ttn&po"ton

2. Mo(e the

patent tothe head-han&n&D'Hallp3epo"ton o$ the a$$e!tedear

3. O%"er(e the

eye" $or @prmary"ta&eny"ta&m#"

4. Mantan th"

po"ton $or 85 mn#te")po"ton *+

5. The head "

t#rned /0Q to

the oppo"te

D'Hallp3e

po"-ton 2hle

3eepn& the

ne!3 n $#ll



e'ten"on

)po"ton C+

6. Contn#e to

roll the

patent

another /0Q

#ntl h" or

her head "

da&onally

oppo"te the

$r"t D'

Hallp3e po"-

ton )po"ton

D+, The

!han&e $rom

po"ton *

thro#&h

C h r i s t i n

e K e n n e y

!ig. <"

Liberat

ory

manoe

u)re o# Semont

&right ear(. The

top panel "ho2"

the e$$e!t o$ the

manoe#(re on

the la%yrnth a"

(e2ed $rom the

$ront and the

nd#!ed

mo(ement o$

the !analth"

)$rom %l#e to

%la!3+, Th"

manoe#(re

rele" on nerta"o that the

tran"ton $rom

po"ton 5 to 6

m#"t %e made

(ery 4#!3ly,

688AMC 60 SEPT,50067 89/ ):+

C nto D"ho#ld ta3e

no lon&erthan 6"e!ond"

7. The eye""ho#ld %emmedatelyo%"er(ed $or @"e!-ondary"ta&eny"ta&m#",I$ thepart!le"!ontn#e

mo(-n& nthe "ameamp#llo$#&aldre!tonthat "thro#&h the!ommon!r#" nto the#tr!le th""e!ondary"ta&eny"ta&m#""ho#ld %eat

n the "amedre!ton a"the pr-mary"ta&eny"ta&m#",

8. Th" po"ton

" mantaned

$or 6090

"e!ond" and

then the

patent "

a"3ed to "t

#p, .th a

"#!!e""$#l

manoe#-(re

there "ho#ld

%e no

ny"ta&m#" or

(ert&o 2hen

the patent

ret#rn" to the

"ttn&

po"ton

%e!a#"e the

part-!le" 2ll

ha(e already

%een

repo"toned

nto the

#tr!le,B6

O(erall the

PRM "ho#ld



ta3e le"" than

mn#te" to

!omplete,

Patent" are then

typ!ally a"3ed

to reman #p-

r&ht $or the ne't

5BB< ho#r" n

order to allo2

the otolth" to

"ettle "o a" topre(ent a

re!#rren!e o$ the

*PPV,

It " d$$!#lt to

!ompare "t#de"

that #"e the

repo"ton-n&

manoe#(re"

%e!a#"e they

(ary

!on"dera%ly n

the len&th o$

$ollo2-#pn#m%er o$

treatment

"e""on"

n#m%er

*en&npar o'y"malpo"tonal(ert&o

o$ manoe#(re"

per "e""on the

#"e o$ "edaton

and the #"e o$

ma"tod

(%raton, The

e$$!a!y and

treatment

proto!ol" o$

many tral" n thelterat#re are

"#mmar=ed n

Ta%le

5,68666/B5B6B5

The o(erall

re"pon"e rate"

ran&e $rom 601

to 8001, Mo"t o$

the"e "t#de" are

!a"e "ere" %#t

Lynn and

!ollea&#e"B9 and

Steener"on andCronnB pro(de

&ood e(-den!e

$rom random=ed

"t#de",

Lateral canalBPPV

'ositioningtechni!es

Se(eral

po"tonn&

te!hn4#e" totreat lateral !anal

*PPV ha(e %een

de(eloped,

Perhap" the mo"t

"mple " the

@prolon&ed

po"ton

manoe#(re

de(eloped %y

Vann#!!h and

!ollea&#e",6 In

!a"e" n(ol(n&



&eotrop!

ny"ta&m#" the

patent le" on h"

or her "de 2th

the a$$e!ted ear

#p $or 85 ho#r",

They had

re"ol#ton n more

than /01 o$ ther

6 patent", S' o$

ther patent"

!on(erted to

po"te-ror !anal

*PPV $or 2h!h

they 2ere

"#!!e""$#lly

treated #"n&

"tandard

repo"tonn&

manoe#(re",

"#peror !anal

#tr!le !#p#la

part!le" n po"teror !anal


!ig. 8"

Particl

e

reposit

ioningmanoe

u)re

&right

ear(.

S!hem

a o$

patent

and

!on!#rr

ent

mo(em

ent o$

po"ter

or

"#pero

r

"em!r

!#lar

!anal"

and

#tr!le,

The

patent

"

"eated

on a

ta%le

a"

(e2ed

$rom

the

r&ht

"de

)A+,

The

reman

n&

part"

"ho2

the

"e4#ental

head

and

%ody

po"to

n" o$ a

patent

lyn&

do2n

a"

(e2ed

$rom

the top,

*e$oremo(n&

the

patent

nto

po"to

n *

t#rn

the

head

BQ to

the

"de

%en&

treated)n th"

!a"e t

2o#ld

%e the

r&ht

"de+,

Patent

n

normal

D'

Hallp3

e

head-

han&n& po"ton

)*+, Part!le"

&ra(tate n an

amp#llo$#&al

dre!ton and

nd#!e

#tr!#lo$#&al

!#p#lar

d"pla!ement

and "#%"e4#ent

!o#nter-

!lo!32"e

rotatory ny"ta&-

m#", Th"po"ton "

mantaned $or

85 mn#te",

The patentJ"

head " then

rotated to2ard

the oppo"te

"de 2th the

ne!3 n $#ll

e'ten"on

thro#&h po"ton

C and nto

po"ton D n a

"teady moton%y roll n& the

patent onto the

oppo"te lateral

"de, The

!han&e $rom

po"ton * to D

"ho#ld ta3e no

lon&er than 6

"e!ond", Part-

!le" !ontn#e

&ra(tatn& n an

amp#llo$#&al

dre!ton thro#&h

the !ommon!r#" nto the

#tr!le, The

patentJ" eye"

are mmedately

o%"er(ed $or

ny"ta&m#",

Po"ton D "

mantaned $or

another 85

mn#te" and

then the patent

"t" %a!3 #p to

po"ton A, D



dre!to

n o$

(e2 o$

la%yrnt

h dar3

!r!le

po"to

n o$

part!le

!on&lo

m-

erate

open

!r!le

pre(o#

"

po"ton,

Adapted $rom

Parne" and

Ro%!ha#d

)Otolaryngol

Head Neck Surg

8//:7889; 56<-

B6+,B

CMA SEPT,

60 50067 89/ ):+

68=

Parne" et al

The @%arrel

roll 2a"

de"!r%ed %y

Epley80B and

n(ol(e" rolln&

the patent 690Q

$rom "#pne

po"ton to

"#pne po-"ton3eepn& the

lateral

"em!r!#lar

!anal

perpend!#lar to

the &ro#nd, The

patent " rolled

a2ay $rom the

a$$e!ted ear n

/0Q n!rement"

#ntl a $#ll roll "

!ompleted, Th"

" %ele(ed to

mo(e the

part!le" o#t o$

the n(ol(ed

!anal nto the

#tr!le, For le""

a&le patent"

Lempert and

Tel-.l!3

propo"ed the

@lo& roll, Here

the patent

%e&n" 2th h"

or her head

t#rned

!ompletely

to2ard the

a$$e!ted ear, The

patent " then

rapdly t#rned

a2ay $rom the

a$-$e!ted ear n

/0 n!rement"

$or a total o$

5:0 2th the

head %en& held

n ea!h po"ton

$or a%o#t 8mn#te, Only 5

patent" 2ere n

the "t#dy %#t

%oth 2ere

!ompletely re-

le(ed o$ ther

(ert&o,

Contro"ersy

De"pte the

e'!ellent re"#lt"

$rom repo"tonn&ma-noe#(re"

there ha" %een

"ome !ontro(er"y

a" to 2hether

they a!t#ally ha(e

an e$$e!t other

than !entral

ha%t#aton that

" 2hen the %ran

adapt" to

repeated

(e"t%#lar "tm#l

o(er tme, In8//B *la3leyB<

p#%l"hed a tral

o$ 6< patent"

randomly

a""&ned to a

part!le

repo"tonn&

&ro#p and a no-

treatment &ro#p,

No "&n$!ant

d$$eren!e 2a"

$o#nd %et2een

the treated andnontreated

&ro#p" at 8

month and

to&ether </1

"ho2ed "ome

mpro(ement,

*la3ley !on-

!l#ded that the

manoe#(re 2a"

"a$e %#t dd not

pro(de any

treatment %ene$t

$or *PPV,



*#!3n&ham9

e'amned h#-

man temporal

%one" and

attempted to

demon"trate the

po""%le path"

ta3en %y loo"e

otolth" #nder the

n$l#en!e o$ &ra(ty n d$$erent

po"ton" o$ the

head, He $o#nd

that altho#&h

loo"e ma!#lar

otolth" 2o#ld

tend to $all nto

the l#men o$ the

#tr!le they 2o#ld

not %e ret#rned to

ther or&nal

po"ton n the

ma!#la o$ the#tr!le 2h!h ha"

a h&her po"ton

n the (e"t%#le,

He !on!l#ded

that a me!h-

an"m other than

the repo"tonn&

o$ otolth" "

re"pon"%le $or

the rele$ o$ *PPV

"een n

repo"tonn&

manoe#(re", Altho#&h

mo"t !a"e" o$

*PPV are "el$-

lmted a

n#m%er o$

random=ed

"t#de" ha(e

"ho2n that

repo"tonn&

ma-noe#(re" are

h&hly e$$e!t(e,

One &ro#p n

Thaland per-

$ormed a 9-

month e$$!a!y

tral !omparn&

the CRP 2th no

treatment n

patent" 2th

*PPV,: At 8

month (ert&o

re"ol#ton 2a"

"&n$!antly

h&her n the

CRP &ro#p

)/B1+ (er"#" the



no-treatment

&ro#p altho#&h

th" d$$eren!e

2a" not "een at

6 and 9 month",

Lynn and

!ollea&#e"B9 ran-

domly allo!ated

69 patent" to

ether a PRM

&ro#p or pla!e%o

treatment &ro#p

2th a""e""ment

at 8 month %y an

a#dolo&"t 2ho

2a" #na2are o$

the patent"J

treatment al-

lo!aton,

Re"ol#ton o$

(ert&o 2a"

"&n$!antly

h&her n the

PRM &ro#p)</1+ !ompared

2th the pla!e%o

&ro#p )5:1+,

Steener"on and

CronnB

randomly

allo!ated 50 pa-

tent" nto ether

a PRM or

(e"t%#lar

ha%t#aton

&ro#p and 50

patent" nto a

no-treatment

&ro#p, At 6

month" all

patent" n the

treatment &ro#p

had re"ol#ton o$

ther "ymptom"

2herea" only

51 o$ the no-

treatment &ro#p

2ere "ymptom

$ree,

5able $"*##icacyo# theparticlerepositioningmanoeu)re #orposterior canal

PP-

Re$eren!e

EpleyB5

EpleyB5

EpleyB5

LB:

LB:

LB:

*la3leyB<

Smo#haB/

.ol$ et al0

Herdman et alParne" and

Pr!e-one"

.eder et al66 BB

Steener"on and 50

CronnB

.elln& and 5

*arne"8

Har(ey et al5 5

Lynn et alB9 8<

Note; NR not reported,Ta%le adapted $romHayne" et al,68

M#ltple entre" $rom the"ame re$eren!e nd!atedata e'tra!ted $rom a"n&le "t#dy that #"edd$$erent treatment" $ord$$erent &ro#p" o$patent",E'!l#dn& patent" lo"tto $ollo2-#p,

6=>AMC 60 SEPT,50067 89/ ):+

actors thata&&ectre'ositioning anoe!"res

;umber o#manoeu)resper session

There are

(araton" n the

lterat#re

re&ardn& ho2

many

repo"tonn&

manoe#(re" are

per$ormed n

ea!h treatment

"e""on )Ta%le 5+,

Some per$ormed

a "et n#m%er o$

repo"tonn&

manoe#(re"

re&ardle"" o$

re"pon"e,< Ho2-

e(er the ma?ortyo$ &ro#p" are

d(ded %et2een

per$orm-n& only

8 manoe#(re per

!ln! ("t and

per$ormn& ma-

noe#(re" #ntl

there " a

re"ol#ton o$

ny"ta&m#" or

e'!e""(e patent

d"!om$ort, O#r

o%?e!ton to



repeatn& the

manoe#(re #ntl

there " a

ne&at(e D'

Hallp3e re-

"pon"e " not

3no2n& 2hether

the re"pon"e "

a%ol"hed

%e!a#"e o$ a

"#!!e""$#l

manoe#(re or

%e!a#"e o$ a

$at&#ed re"pon"e

that o!!#r"

nat#rally 2th

repeat te"tn&,

From the

lterat#re re(e2

there doe" not

appear to %e any

"&n$-!ant

d$$eren!e

%et2een the"e

approa!he" n

term" o$ "hort-

term

e$$e!t(ene"" and

lon&-term

re!#rren!e,

There$ore n o#r

!ln! repeat

manoe#(re" are

re"er(ed $or

tho"e pa-tent"

2ho do not

demon"trate anp"dre!tonal

"e!ondary "ta&e

ny"ta&m#" or

tho"e 2ho ha(e a

re(er"e-dre!ton

ny"-ta&m#" at

po"ton D5B )F&,

<+,

S4ull )ibration

In EpleyJ"

or&nalde"!rpton o$ the

CRPB5 he #"ed

me!han!al

(%raton o$ the

ma"tod )"3#ll+

%one thn3n&

that t 2o#ld help

loo"en otolth!

de%r" adherent

to the mem%rane

o$ the

"em!r!#lar

!anal, In 8// a

"t#dy %y LB:

randomly

a""&ned 5:

patent" to

re!e(e the PRM

2th ma"tod

(%raton and 80

patent" to

re!e(e the PRM

2tho#t ma"tod

(%raton, He

$o#nd that the

(%raton &ro#p

had a

"&n$!antly

h&her rate o$

mpro(ement n

"ymptom" )/51+

!ompared 2th

the non(%raton

&ro#p )901+,

The"e re"#lt" do

not ho2e(er

!ompare 2ell2th the lterat#re

)Ta%le 5+ 2here

the ma?orty o$

a#thor" 2ho dd

not #"e ma"tod

(%raton

a!he(ed m#!h

h&her "#!-!e""

rate", In 5000 a

lar&er "t#dy %y

Han and

!ollea&#e"<

re(e2ed BBpatent" 2ho had

the PRM 2th

ma"tod (-

%raton and 0

patent" 2ho had

the PRM 2tho#t

ma"tod

(%raton, There

2a" an o(erall

"#!!e"" rate o$

:<1 2th no

d$$eren!e n

"hort-term or lon&-term

o#t!ome" %e-

t2een the 5

&ro#p",

Postmanoeu)r e instructions

Another area

o$ d(er&en!e

amon& e'pert"

n(ol(e" the #"e

o$ a!t(ty



lmtaton" a$ter

repo"tonn&

manoe#(re",

EpleyB5 a"3ed h"

patent" to reman

#pr&ht $or B<

ho#r" a$-ter the

CRP, In addton

to remann&

#pr&ht !ertan

n(e"-t&ator"

al"o re4#e"t that

ther patent"

a(od lyn& on

ther a$$e!ted "de

$or : day", A

"t#dy %y N#t and

!ollea&#e"B0 e'-

amned 5 "et" o$

patent" $ollo2n&

the l%eratory

manoe#(re, One

&ro#p o$ patent"

2ere a"3ed to

reman #pr&ht $or

B< ho#r"

2herea" a

"e!ond &ro#p o$

patent" 2ere not

&(en

*en&npar o'y"malpo"tonal(ert&o

anypo"tmanoe#(ren"tr#!ton",The"e 5 &ro#p"2ere !om-paredretro"pe!t(elyand nod$$eren!e 2a"$o#nd n "hort-

term (ert&o!ontrol, Th"$ndn& "!on""tent 2than ear-ler pro"pe!t(e"t#dy %yMa""o#d andIreland/ 2hoal"odemon"tratedthat po"tl%eratory

manoe#(ren"tr#!ton"2ere note$$!a!o#",

Surgicaltreatment

*PPV " a

%en&n d"ea"e

and there$ore

"#r&ery "ho#ld

only %e re"er(ed

$or the mo"tntra!ta%le or

m#ltply re!#r-

rent !a"e",

F#rthermore

%e$ore

!on"dern&

"#r&ery the

po"teror $o""a

"ho#ld %e

ma&ed to r#le

o#t !entral

le"on" that



m&ht mm!

*PPV,90

#ing!larne!rectoy

Sn&#lar ne#re!tomy or "e!ton o$ thepo"teror am-p#llary ner(e2h!h "end"mp#l"e"e'!l#"(ely $romthe po"teror "em!r!#lar !anal to the%alan!e part o$ the %ran 2a"pop#lar=ed %yGa!e398 n the8/:0", Altho#&hntal report" %yGa!e395

demon"tratedh&h e$$!a!ythere 2a" a"&n$!ant r"3o$ "en"orne#ralhearn& lo""96

and the pro-!ed#re ha"%een $o#nd to%e te!hn!allydemandn&, Itha" lar&ely

%een repla!ed%y the "mpler po"teror "em!r!#lar !analo!!l#"on,5/

Posteriorseicirc!larcanaloccl!sion

Parne" and

M!Cl#re9B99

ntrod#!ed the

!on!ept o$ po"-

teror "em!r!#lar

!anal o!!l#"on

$or *PPV,

O%"tr#!ton o$ the

"em!r!#lar !anal

l#men " tho#&ht

to pre(ent en-

dolymph $lo2,

Th" e$$e!t(ely

$'e" the !#p#la

and render" t

#nre"pon"(e to

normal an&#lar

a!!eleraton

$or!e" and more

mportantly to

"tm#laton $rom

ether $ree-

$loatn& part!le"

2thn the

endolymph or a

$'ed !#p#lar

depo"t, Untl the

ad(ent o$ th"

pro!ed#re

n(a"(e nner ear

"#r&ery 2a" $elt

to %e too r"3y to

other2"e normal-

hearn& ear",

Ho2e(er Parne"

and M!Cl#re9:

lad the

&ro#nd2or3 $or th" pro!ed#re n

an anmal model

%y demon"tratn&

t" ne&l&%le

e$$e!t on hearn&,

The pro!ed#re

" per$ormed

#nder &eneral

ane"thet! and

"ho#ld ta3e no

lon&er than 56

ho#r", U"n& a

9-!mpo"ta#r!#lar

n!"on the

po"teror !anal "

a!!e""ed thro#&h

a ma"tode!tomy,

.th the #"e o$

an operatn&

m!ro"!ope and

drll a 8-mm × 6-

mm $ene"traton

" made n the

%ony po"teror

!anal, A pl#&$a"honed $rom

%one d#"t and

$%rno&en &l#e "

#"ed to o!!l#de

the !anal, Mo"t

patent" "tay n

ho"ptal $or 56

day" a$ter th"

pro!ed#re,

*e!a#"e the

o!!l#"on al"o

mpar" the

normal nner ear



phy"olo&y all

patent" are

e'pe!ted to ha(e

po"toperat(e

m%alan!e and

d"e4#l%r#m,

For mo"t people

the %ran adapt"

to th" a$ter a $e2

day" to a $e2

2ee3" 2th(e"t%#-lar

phy"otherapy

ha"tenn& th"

pro!e"",

In 5008

A&ra2al and

Parne"< p#%l"hed

a "ere" o$ !a"e"

o$ BB o!!l#ded

po"teror !anal"

n B5 patent", AllBB ear"

CMA SEPT,

60 50067 89/):+

6=

Parne" et al

2ere rele(ed o$

*PPV 2th only 8

ha(n& a late

atyp!al

re!#rren!e, O$

the B0 ear" 2th

normal

preoperat(e

hear-n& 8 had a

delayed )6-

month+ "#dden

and permanent

pro-$o#nd lo""

2herea" another

had mld )50 d*+

hearn& lo"",

F#rther

"t#de" %y Pa!e-

*al=an and

R#t3a9< Dn&le

and

!ollea&#e"9/

Ha2thorne and

el-Na&&ar:0

Anthony:8 and

.al"h and

!ollea&#e":5

ha(e "#pported

the "a$ety and

e$$-!a!y o$ th"

pro!ed#re, In

mo"t otolo&y

!ln!" po"teror

"em!r!#lar

!anal o!!l#"on

ha" %e!ome the

"#r&!al pro!e-

d#re o$ !ho!e

$or ntra!ta%le

*PPV,

+onclusion

Patent" 2th

*PPV pre"ent

2th a h"tory o$

%re$ ep"od!

po"ton-pro(o3ed

(ert&o 2th

!hara!ter"t!

$ndn&" on D'

Hallp3e te"tn&,.herea" a

(arety o$ po-

"tonal

manoe#(re" ha(e

%een de"!r%ed

PRM )F&, <+ " a

"mple e$$e!t(e

treatment $or

mo"t patent" 2th

o%?e!t(e or

"#%?e!t(e *PPV,

C#rrent e(den!e

doe" not "#pport

the ro#tne #"e o$

"3#ll (%raton

2th repo"tonn&,

Altho#&h mo"t

!ln!an" are "tll

ad("n& patent"

to reman #pr&ht

$or 5BB< ho#r"

a$ter

repo"tonn&

re!ent e(den!e

"#&-&e"t" that

th" "

#nne!e""ary, Inaddton the

lterat#re "

e4#(o!al

re&ardn& the

deal n#m%er o$

repo"tonn& ma-

noe#(re" to

per$orm per

treatment

"e""on, To date

no $a!tor" ha(e

%een dent$ed to



nd!ate an

n!rea"ed r"3 o$

*PPV re!#rren!e

a$ter "#!!e""$#l

repo"tonn&

ho2e(er the

a""o!aton

%et2een *PPV

re!#rren!e and

m&rane 2arrant"

$#rther

n(e"t&aton, For

the "mall &ro#p o$

pa-tent" 2th

!la""! po"teror

!anal *PPV 2ho

do not re-"pond

to repo"tonn&

po"teror !anal

o!!l#"on " a

"a$e and h&hly

e$$!a!o#"

pro!ed#re,

Th" art!le ha" %eenpeer re(e2ed,

All a#thor" are 2th the

Department o$

Otolaryn&olo&y

Un(er"ty o$ .e"tern

Ontaro London Ont,

Competing interests:None de!lared,

Contributors: Dr, Atla"

2a" re"pon"%le $or the

ntal lterat#re re(e2

and $r"t dra$t, Dr,

A&ra2al per$ormed a

more n-depth re(e2

and ma?or man#"!rpt

re(-"on, Dr, Parne"

"#per("ed and $nal=ed

the man#"!rpt and 2th

the ll#"trator !reated

the $&#re", All a#thor"

&a(e $nal appro(al to

the p#%l"hed (er"on,

?e#erences

1. at"ar3a" A,

*en&nparo'y"mal

po"tonal (ert&o)*PPV+; dopath!

(er"#" po"t-tra#mat!, Acta

Otolaryngol

8///788/):+;:B-/,

2. *>r>ny R,

Da&no"e (onran3het"er"!her n#n&en n*ere!he de"Otolthenapparate", ActaOtolaryngol (Stock!8/5875;B6B-:,

3. Dohlman G,

In(e"t&ator" nthe $#n!ton o$ the

"em!#r!#lar !anal", ActaOtolaryngol Suppl (Stock!8/BB78;588,

4. Hall SF R#%y RR

M!Cl#re A, Theme!han!" o$ %en&nparo'y"mal (er-t&o, J Otolaryngol 8/:/7<)5+;88,

5. Parne" LS

M!Cl#re A, Free-$loatn&endolymphpart!le"; a ne2operat(e $ndn&d#rn& po"teror "em!r!#lar !analo!!l#"on,"aryngoscope8//57805 )/+;/<<-/5,

6. S!h#3ne!ht HF,

C#p#loltha"", Arc Otolaryngol 8/9/7/0;:9,

7. S!h#3ne!ht HF

R#%y RR,C#p#loltha"",

Ad# Otorinolaryngol 8/:6750;B6B,

8. A&ra2al S

Parne" LS,H#mane'peren!e 2th!anal pl#&&n&, Ann N $ Acad Sci 50087/B5;600-,

9. Epley M, Ne2

dmen"on" o$ %en&nparo'y"malpo"tonal (ert&o,Otolaryn%gol Head Neck Surg 8/<07<<;//-90,

10.Epley M, H#man

e'peren!e 2th!analthrepo"tonn&mane#(er", Ann N



$ Acad Sci50087/B5;8:/-/8,

11.Cohen * S#=#3

I *ender M*,Eye mo(ement"$rom "em!r!#lar !anal ner(e"tm#laton n the!at, Ann

Otolaryngol 8/9B7:6;86-9/,

12.Uno A Mor2a3

ato T Na&a M

Sa3ata , WCln!al

$eat#re" o$ %en&n

paro'y"mal

po"tonal (ert&oX,

Nippon Jibiinkoka

&akkai 'aio

5008780B;/-89,

13.Ned=el"3 M

*ar%er HOM!Ilmoyl L,Da&no"e" n ad==ne"" #nt, J Oto%laryngol 8/<978;808-B,

14.M=#3o"h

.atana%e Sho?a3# H O3#%o .atana%e I,Epdemolo&-!al"t#de" on %en&nparo'y"malpo"tonal (ert&on apan, ActaOtolaryngol Suppl 8/<<7BB:;9:-:5,

15.*aloh R.

Honr#%a Va!o%"on ,*en&n po"tonal(ert&o; !ln!aland o!#lo&raph!$eat#re" n 5B0

!a"e", Neurology 8/<:76:;6:8-<,

16.*o#r&eo" PM

Dehaene I, *en&n

paro'y"mal

po"tonal (ert&o

)*PPV+, Cln-!al

$eat#re" n 6B !a"e"

and re(e2 o$

lterat#re, Acta

Neurol elg

8/<<7<<;9-:B,

17.Oa" G, *en&n

paro'y"malpo"tonal (ert&o;a !ln!anJ"per"pe!t(e, AnnN $ Acad Sci

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o(a!h *T

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Treatment o$

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e$$!a!y n patent"

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ny"ta&m#",

"aryngoscope

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6=$AMC 60SEPT, 50067

89/ ):+




45.Steene

r"on

RL

Cronn

G.,

Comp

ar"ono$ the

!analt

h

repo"t

onn&

pro-

!ed#re

and

(e"t%#

lar

ha%t#

aton

trann

& n

$orty

patent

" 2th

%en&n

paro'-

y"mal

po"to

nal

(ert&o

,

Otolar

yngol

Head

Neck

Surg

8//978

8B;98-

B,

46.Lynn

S

Pool A

Ro"e

D

*rey

R

S#man

V,

Rando

m=ed

tral o$

the

!analt

h

repo"t

onn&

pro!ed

#re,

Otolar

yngol

Head

Neck

Surg 8//78

867:85

-50,

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Ma"todo"!llaton; a!rt!al$a!tor $or "#!!e"" n!analthrepo"ton-n&

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50..ol$ S

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56.*#!3n&ham

RA,

Anatom!al

and

theoret!al

o%"er(aton"

on oto lth

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n& $or

%en&n

paro'y"mal

po"tonal

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e8///780/;:8

:-55,

57. A"a2a(!h

an&nda SI"pradt PSnd(on&"S#pyaph#nP, Canalthrepo-"tonn& $or %en&nparo'y"malpo"tonal(ert&o; arandom=ed

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Po"t-

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ent

n"tr#!t

on" n

the

non"#r

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man-

a&eme

nt o$

%en&n

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"mal

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nal

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J

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M!Cl#re A,Po"teror

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72..al"h RM



*ath APC#llenRR#t3aA,Lon&-termre"#lt"o$ po"teror "em!r!#lar

!analo!!l#"on $or ntra!t

a%le %en&nparo'y"malpo"tonal(er-t&o,ClinOtolaryngol 8///75B;689-56,

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