The quick answer is no the Epley maneuver does not work for horizontal or superior canal BPPV but only for the more common posterior canal form of BPPV. The good news about that, however, is that those other two types are easier to treat.

First – superior canal BPPV is theoretical and may not actually exist in any significant clinical form. This is because BPPV is caused by the settling of lose “otoconia” in the inner ear. This can only happen in the lowest areas of the inner ear. For example – dust does not settle on the ceiling, rather it settles on the floor. The same is true of the inner ear. The particles settle, typically in the posterior canal because it is the lowest area and it is not tipped upside down by regular activity. By contrast – the superior canal is emptied every time you lie down and stand up. So, while it is possible to have crystals in that canal, it is not possible to have then “get stuck” there and cause BPPV.

The same is true, to some degree, with the horizontal canal. Whenever you roll over (like a log roll) the canal is emptied. So many times simply sleeping at night (when you may roll over) is curative for that condition. It is, however, more intense vertigo than posterior BPPV. It is worth noting that horizontal BPPV can sometimes be induced by the treatment maneuvers for posterior BPPV as the crystals may fall out of the posterior canal and temporarily fall into the horizontal canal.

Finally, posterior BPPV is the most common kind as the anatomy of the canals allows for collection of the crystals in the lowest part of the ear. In addition, neither rolling over nor lying down and getting up again will cause the crystals to empty out. The main treatment for this condition is the “particle repositioning maneuver” or Epley maneuver.

If you are having symptoms which don’t fit the norm make sure you discuss them with your own physician.

Until recently very few people knew about Mal de Debarquement syndrome. This syndrome can occur after any type of travel. The best analogy is sea sickness. When you first step onto a boat you might feel sea sick due to the constant motion of the boat. After a few days you get used to it and the sensation goes away. However, the same can happen when you get off the boat. The land may feel like it is moving. Anyone who has used roller skates, skis or ice skates can attest to how strange it feels after a few hours of skating or skiing and then returning to your street shoes. The same is true after getting off a boat. It may take hours to weeks to get used to land. In some people this adjustment never happens and they feel sea sick on land forever. We call this Mal de Debarquement, or sickness after disembarking.

Mal de Debarquement and BPPV can be differentiated in a couple of ways.

1)BPPV is positional in onset meaning that it will not occur unless you move into a certain position.
2)BPPV is also short lived rather than continuous. Mal de Debarquement syndrome should be continuous.
3)Mal de Debarquement can occur, and perhaps be worse, when stationary. It is the sensation of motion where there is no actual motion. This is different than BPPV which is the sensation of spinning (either you spinning or the world spinning around you)

The Epley maneuver or devices which assist with the treatment maneuver only work with BPPV. That is not to say that you cannot have both, but we always suggest you see your own doctor and get a diagnosis of BPPV prior to using any treatment method.

BPPV (Benign paroxysmal positional vertigo) in children can easily be confused with BPV of Childhood (Bengin paroxysmal vertigo) which is actually a migraine related phenomenon.  It is unfortunate that the names are so close as they are not related disorders.  The primary distinguishing difference is that BPPV can be brought on with position change and is due to otoconia whereas BPV is often associated with headache and not affected by position.

BPPV is most commonly seen in people over the age of 60 as they are most likely to have age related changes to their ears which causes the otoconia to come loose.  While it is possible to see BPPV in children it is uncommon and often short lived.  Careful attention should be paid to differentiate causes of vertigo in all patients.

BPPV is indeed a chronic disease.  The otoconia, (normal balance crystals) which cause the symptoms of BPPV when in the wrong place, do not disappear when treated with the Epley Maneuver or with home BPPV treatment, rather the particles are moved.  More than 50% of people will have BPPV more than once and many will have it on a regular basis and some will even have it daily, even if treated properly.

The key to successful treatment of BPPV is to understand how to identify it and how to properly treat it.  BPPV is characterized by sudden spinning, which is short lived and comes on only in certain positions.

Following treatment most people obtain resolution of symptoms immediately.  Even in the worst of cases some duration of symptom free period can be achieved.  Many people report recurrent symptoms within weeks or months of the original attack.

Patients with BPPV on one side often are at risk of having it on the second side. There is no know family predeliction to BPPV.  Rates of BPPV also increase dramatically with age to more than 1 in 10 over the age of 60.

]]> http://clearwaterclinical.com/blog/2009/06/how-long-will-i-have-bppv.html/feed 0 http://clearwaterclinical.com/blog/2009/06/i-tried-the-epley-maneuver-but-it-didnt-work.html http://clearwaterclinical.com/blog/2009/06/i-tried-the-epley-maneuver-but-it-didnt-work.html#comments Tue, 09 Jun 2009 15:00:55 +0000 admin http://clearwaterclinical.com/blog/?p=83 Although most people with BPPV can be treated with the Epley maneuver or a home treatment device.  About 5-12% of people cannot be treated.  There are several reasons which should be carefully considered.

1) You do not have BPPV.  There are many kinds of vertigo and only BPPV will respond to the Epley maneuver.  You should always get a proper diagnosis from a physician qualified to diagnose BPPV.  Several serious conditions can cause vertigo as part of their symptom complex and these other conditions should be ruled out.

2) You have BPPV but are doing the maneuver incorrectly.    This is actually the most common reason for treatment failure in people with BPPV.  This may be because you are treating the wrong side or may be because you are performing the maneuver too quickly, with the wrong angles or in the wrong order.  The maneuver is only effective when performed totally correctly.  A BPPV treatment device to assist in the correct performance of the maneuver is available and will visually guide a person through the maneuver.

3) You may have a resistant form of BPPV.  This may be due to the fact that the otoconia, or ear crystals, get stuck in the balance canal or that they get glued to the end of the canal. It is not clear which is true but it seems that some people don’t respond whatever they do.

4) You may have BPPV in both ears.  Due to the nature of BPPV if you have it in one ear it is certainly possible to get it in both ears.  Typically this will present with symptoms on both sides.  A physician can tell you if this is the case.  The Epley maneuver will still work but you will have to do it on both sides.  People often ask if doing one side and then the other will reverse the benefit of the first maneuver. It is not clear that this is true however, we always tell people to treat one side one week then the other side the next week.

With these issues in mind it doesn’t hurt to perform an Epley maneuver in a repeated fashion, it might help but this cannot be guaranteed.    The only caution is that if you have symptoms which do not seem related to BPPV such as weakness or confusion you should seek medical attention.

BPPV is characterized by spinning vertigo when changing into certain positions.  These are typically rolling over in bed, looking up and to the side, or looking under something.  Often it happens on a specific side, either left or right, although some unlucky people have BPPV on both sides.  Many people who have BPPV are afraid to travel in case an attack comes on while away from their own physician.  Devices for the treatment of BPPV are available to take with you when away from home.

Motion sickness is a sensation of “Disequilibrium” or being off balance, or feeling like you are moving when you are not.  It is caused by a disjunction between what you see and what you feel, or between what you feel and what your ear is telling you.  A good example of this is when the car beside you at a traffic light rolls backward and it makes you feel like you are rolling into the intersection (your eyes tell you that you are moving but your body and balance organ say you are still).  Not only is this a bit anxiety provoking but it often causes an uncomfortable sickness feeling of disequilibrium.  Another good example is the familiar sensation of reading in a moving car.  Your eyes tell you that you are sitting still, since you are looking at a book, but your ear and body tell you that you are moving.  It is this disjunction that is the culprit in motion sickness.

There is also an under-diagnosed but interesting phenomenon called “Mal de Debarquement” syndrome.  Everyone has heard of sea-sickness (a type of motion sickness) but this happens when you get off the boat.  Typically the individual has not had sea-sickness and is the envy of everyone else until they step back onto dry land. Then they still feel like they are on a boat.  In some cases this is temporary but in others it is permanent.  These people may be seen swaying down the streets as if on board a boat in rough seas.  It is a difficult and very frustrating problem for which there is currently no cure.

In general, traveling with vertigo can be scary.  Tips on traveling can be found at http://jetseventravel.com.  In order to overcome vertigo and get back to living your life, learn as much as you can about your own condition and travel with adequate preparation.  For example, if you get motion sick bring anti-nauseant medication (Gravol/Antivert/Dramamine), if you have Menieres disease, Serc can be useful, and if you have BPPV learn the treatment maneuver or take a self treatment device with you.

In general terms, it may take several attempts to fully treat BPPV and most people can expect to have some recurrences.  We suggest that you need only perform the maneuver when you have an attack.  If you are not having symptoms then you don’t need to to do the maneuver although it may prevent recurrences.  It is always important to seek the advice of your own doctor to obtain a diagnosis and to monitor your condition.

With that said here are several important questions to ask yourself about failed BPPV treatment.

1. Do you have BPPV?
   1. To achieve success with the Epley Maneuver or home treatment for BPPV you must be sure you have a correct diagnosis. These maneuvers do not work if you do not have BPPV.  There are many other types of dizziness, although BPPV is the most common.
   2. Posterior BPPV?
      1. There are actually a number of sub-types of BPPV.  Posterior canal BPPV (P-BPPV) is by far the most common.  The Epley maneuver treats P-BPPV but not the others.
2. Did you do the maneuver correctly?
   1. Although the treatment maneuvers for BPPV are very effective it is not yet clear how incorrectly you can perform them and still have success.  The major reason for home treatment failure is an incorrectly performed maneuver . Home BPPV treatment devices are designed to minimized this problem.  Careful attention to detail in the maneuver as well as ensuring the correct angles, side and duration will improve success.  The most common mistake,..not putting you head back far enough (it can be too far though).
3. Do you have bilateral BPPV?
   1. A small percentage of people will have BPPV on both sides and so after successful treatment on one side will still have symptoms.  This can be confusing.  We recommend that people treat one side daily for one week then switch to the other side.
4. Do you have recurrent BPPV?
   1. BPPV treatment does not cure the problem it only removes the stimulus temporarily so as many as 60% of people will have symptoms more than once.   Some people have highly recurrent BPPV so after they successfully treat one episode it can come back in a matter of days and make them think they failed in their maneuver.  Daily maneuvers may control these problems.  In rare cases of very symptomatic and resistant BPPV surgery can be performed to block of the balance canal which causes BPPV.
5. Are you ever going to respond?
   1. Do you have something else as well?
      1. BPPV can be found along with any other disease which causes inner ear damage.  Conditions like Menieres, head trauma, or inner ear infections may causes BPPV.  As such it can be confusing as to which condition is causing the vertigo.  Generally these symptoms can be sorted out by a skilled ear doctor.  You might need help with this one.
   2. Do you have resistant BPPV?
      1. About 5% of people have BPPV which is resistant to maneuvers.  This may be because the disease causing crystals are too large to come out of the posterior canal or that they are stuck to the inner ear somewhere.   Regardless the Epley maneuver does not work for these people.  Again in certain circumstances surgery may be indicated.

In BPPV there is a phenomenon known as positional nystagmus.  When a person with BPPV is in a position which causes them dizziness their eyes exhibit a characteristic motion, called nystagmus. What happens is the inner ear perceives that body is moving (this is the vertigo associated with BPPV) and tells the eyes to move to keep up. The only problem is that the body is not moving, and having your eyes move involuntarily while you are still can be quite disconcerting.

You can see a video of Nystagmus related to BPPV on Youtube.

The maneuver in the video is called “Dix-Hallpike Maneuver” and it elicits the symptoms of BPPV and, more specifically, the nystagmus.  There are many types of nystagmus but there are a few qualities of which make the diagnosis of BPPV easier.

Nystagmus associated with BPPV has to have the below characteristics:

1. Positional in onset (only in a head hanging position will it come on)
2. Short lived (lasts only a few seconds to minutes)
3. Geotropic – the top of the eye beats (fast phase) toward the side on which your head is hanging
4. Rotatory and small upbeat component – the eye rotates or twists, as above, and has a slight fast phase up motion
5. Fatigable – repeating the maneuver again and again will stop it from happening temporarily
6. Latent onset – there is a slight lag phase of a few seconds before the nystagmus starts when in the head hanging position.

So why do you get nystagmus with BPPV?  Well that can be the subject of another post.

1. Disequilibrium

   Disequilibrium is the sensation of being off balance, much like when getting off a boat, and is sometimes characterized by falls in a specific direction. This condition is not often associated with nausea or vomiting or vertigo.

2. Pre-syncope

   Pre-syncope (literally near fainting) or lightheadedness, like when standing up too quickly. Pre-syncope is often related to low blood pressure.  If loss of consciousness occurs in this situation, it is termed syncope (fainting).

3. Vertigo

   Vertigo is a specific medical term used to describe the sensation of spinning or having the room spin about you. Many people find vertigo very disturbing and often report associated nausea and vomiting.

   If the vertigo arises from the inner ear, it is severe and has associated nausea and vomiting. One common cause of otologic vertigo is benign paroxysmal positional vertigo (BPPV). Alternate causes of vertigo originating from the inner ear include Ménière’s disease, superior canal dehiscence syndrome, and labyrinthitis.

If vertigo arises from the balance centers of the brain, it is milder, and has accompanying neurologic deficits, such as slurred speech, double vision or nystagmus. Alternately, brain pathology can cause a sensation of disequilibrium which is an off-balance sensation.

Being able to identify and discuss these different symptoms will help you and your physician narrow down your problem and possibly come up with a treatment for you vertigo.