Treatment of benign paroxysmal positional vertigo. A clinical review

Abstract

Benign paroxysmal positional vertigo (BPPV) is the most frequent episodic vestibular disorder. It is due to otolith rests that are free into the canals or attached to the cupulas. Well over 90% of patients can be successfully treated with manoeuvres that move the particles back to the utriculus. Among the great variety of procedures that have been described, the manoeuvres that are supported by evidenced-based studies or extensive series are commented in this review. Some topics regarding BPPV treatment, such as controlling the accuracy of the procedures or the utility of post-manoeuvre restrictions are also discussed.

Keywords: Benign Paroxysmal Positional Vertigo; Treatment; Vestibular disorder.

Fig. 1

Epley manoeuvre for treating posterior canal canalolithiasis (depicted for a right-sided pc-BPPV). 1) The patient is seated with the head turned 45° to the affected side (right in this case). 2) The patient is tilted back with the neck in slight extension. 3) The head is turned 90° to the healthy (left in this example) side. 4) The entire body is rotated 90° until the patient is laying on the healthy side, while keeping the head position against the trunk. 5) The patient is raised to the initial position. Then the head is turned towards the front. Each position is maintained 1 min or until the induced nystagmus has extinguished.

Fig. 2

Semont manoeuvre for treating posterior canal canalolithiasis (exemplified for a right-sided pc-BPPV). 1) The patient is seated with the head turned 45° to the healthy side (left in this case). 2) The patient is quickly moved to lie on the affected side (right in this picture). 3) The patient is suddenly turned 180° to lay on the unaffected side while maintaining the position of the head relative to the trunk. 4) The patient is raised to the initial position.

Fig. 3

Lempert (Barbeque) manoeuvre for treating horizontal canalolithiasis (depicted for a right-sided hc-BPPV). 1) Starting supine position. 2) Head rotation toward the healthy side. 3) Head rotation the nose down position. 4) Final head turn to the affected-ear-down position and sitting up. (The body is rotated between the head movements). Each position is maintained for 60 s or until the provoked nystagmus is dissipated. If the manoeuvre is going well, the quick phases of the nystagmus should beat to the healthy side (ampullofugal nystagmus).

Fig. 4

Tirelli manoeuvre for treating horizontal canal cupulolithiasis (depicted for a right cupulolithiasis). 1) Starting supine position. 2) The head is first rotated to the affected side. 3) The head is rotated to the healthy side. 4) Head rotation the nose down position. 5) Final head turn to the affected-ear-down position and sitting up. (The body is rotated between the head movements). Each position is maintained for 60 s or until the provoked nystagmus is dissipated. If the manoeuvre is going well, the quick phases of the nystagmus should beat to the healthy side (ampullofugal nystagmus).

Fig. 5

Gufoni manoeuvre for treating canalolithiasis of the horizontal canal (depicted for a right-sided hc-BPPV). 1) Patient seated head-straight 2) The patient is brought down on the healthy side from the sitting position. 3) The head is turned down 45° (nose is on the bed). 4) The patient is returned to the upright position. Each position is maintained for 60 s or until the provoked nystagmus is dissipated. If the manoeuvre is going well, the quick phases of the nystagmus should beat to the healthy side (ampullofugal nystagmus).

Fig. 6

Appiani manoeuvre for treating cupulolithiasis and anterior arm canalolithiasis of the horizontal canal (depicted for a right-sided horizontal canal cupulolithiasis). 1) The patient is seated head-straight. 2) The patient is brought down on the affected side from the sitting position. 3) The head is turned 45° upright (nose directed upward). 4) The patient is returned to the upright position. Notice that the canalith may just reach the posterior arm of the canal, instead of attaining the utriculus. Each position is maintained for 60 s or until the provoked nystagmus is dissipated. If the manoeuvre is going well, the quick phases of the nystagmus should beat to the healthy side (ampullofugal nystagmus).

Fig. 7

Yacovino manoeuvre for treating canalolithiasis of the anterior canal (for both, left and right-sided anterior canal BPPV). 1) Patient sitting head straight. 2) The patient is brought backward to the head-hanging position. 3) The head is moved forward “chin to chest”. 4) The patient is returned to the sitting position. Each position is maintained for 30 s.