Almost 1 year ago, October 31st, 2017, a really cool and interesting case of BPPV walker-ed into the clinic. I think this case study hits on a few good points of how BPPV isn't always straight forward, how debilitating it can be for a patient, and just how important thorough evaluation techniques are. Let's jump in...
Patient's Subjective History
Significant Medical History
Initial Evaluation Form & Findings
Dix-Hallpike IVOG Test
Canalith Jam-Like Symptoms
After digging into some research, and sitting down with The Functional Inner Ear, I came to the conclusion that the patient had something similar to a Canalith Jam in her right horizontal semicircular canal. She was habitually a right sided sleeper (when she wasn't so symptomatic that she chose to sleep sitting up), and she has been symptomatic now for over a year. Multiple attempts of Epley maneuvers were performed, placing her in dependent positions for free floating otoconia/debris to drop into her canals. She also occasionally woke up lying on her right side at night. I think that all this time, while attempts were being made to treat the posterior canal, she kept building up debris in her horizontal canal.
Everyone's anatomy varies to some degree, and that includes the Vestibular Organ. Some people may have stenotic narrowing of their canals, or maybe the alignment of the canals are a little off from "normal". I came across the article "Persistent Direction-Fixed Nystagmus Following Canalith Repositioning Maneuver for Horizontal Canal BPPV: A Case of Canalith Jam" by Chang et al. They quoted John Epley's canalith jam definition: freely moving otoconial particles block the endolymphatic flow. They also noted two theories for the cause of a canalith jam:
So in this case, I hypothesized that the patient had enough debris in her canal to roll around triggering BPPV canalithiasis-type symptoms and related nystgamus. However, when I tried to move her into a Gufoni Repositioning maneuver, the debris sat at the posterior aspect of a narrowed horizontal canal, and blocked the flow of endolymph, thus preventing associated nystagmus and vertigo.
Here is a rough illustration of what I am trying to explain. In this diagram, the patient would be side-lying on her left, as if she were in the first position of a modified Right Gufoni Maneuver. The red dot represents where I think the bolus was resting in the canal in this position. The bolus was bottle-necked here, and also still able to roll around the canal enough to trigger symptoms and nystagmus with positional changes.
The previously mentioned study disclosed what methods they used to treat their case of a right horizontal canal, canalith jam. They had their patient perform frequent head shaking and maintained left prolonged side lying. In my patient's case, there was no way she was going to actively shake her head, or lie down flat on her side. This was going to be a little more complicated.
Manual Mastoid Vibration in Sitting
Forced Prolonged Side Lying
LE Strength Training
Here are a few things I took away from this case:
To Vibrate, or Not To Vibrate
The study “The Skull Vibration-Induced Nystagmus Test of Vestibular Function—A Review” by Dumas et al. gives a list of patients you should cautiously use vibration testing with:
These conditions should be greatly taken into consideration while using vibration as a treatment as well if vibration will be applied for possible longer lengths of time.
Vibration for treatment should also be used cautiously with patients who are more likely to "shed otoconia". Do they have a history of vestibular neuritis/labyrinitis, Meniere's disease, osteoporosis, recurrent BPPV..? If so, the clinician should be aware that applying vibration may cause additional otoconia/otolithic membrane to fall off and wander into the semicircular canals. The patient may experience worsening symptoms during treatment and/or require additional maneuvers. They may also require additional considerations for post maneuver precautions.
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