Egyptian Journal of Ear, Nose, Throat and Allied Sciences (2015) 16, 161–166

H O S T E D BY
Egyptian Society of Ear, Nose, Throat and Allied Sciences

Egyptian Journal of Ear, Nose, Throat and Allied

Sciences
www.ejentas.com

ORIGINAL ARTICLE

Diagnosis and management of posterior

semicircular canal benign paroxysmal positional
vertigo: A practical approach
a,* b
Hanaa Hussein Elsanadiky , Yasser A. Nour

a
ENT Department, Audiology Unit, Faculty of Medicine, Tanta University, Egypt
b
Faculty of Medicine, Alexandria University, Egypt

Received 13 February 2015; accepted 26 May 2015

KEYWORDS Abstract Objectives: To identify variables affecting outcome in patients with unilateral and bilat-
BPPV; eral BPPV.
Unilateral; Materials and methods: Retrospective review of 220 patients diagnosed with posterior SCC
Bilateral underwent treatment successfully with Canalith Repositioning Maneuver. Bilateral and severe cases
received medical treatment before starting the maneuver. Scheme for management of the cases had
been settled.
Results: One hundred seventy-four patients (74.5%) as the first BPPV episode while 25.5% with
recurring episodes. Significant improvement was reported in 84% of patients. Etiology is not play-
ing a role in unilateral or bilateral BPPV. Patients presented with bilateral BPPV were classified into
true or unilateral mimicking bilateral BPPV. 46.7% of the patients reported sleeping using one pil-
low. Daily routine Brandt–Daroff exercises after the success of CRM affect the rate of recurrence.
Conclusion: Canalith repositioning Maneuver provides rapid relief of symptoms of BPPV.
Patients with bilateral or severe BPPV required a special protocol to reach complete relief. In addi-
tion daily routine Brandt–Daroff exercises decrease the recurrence rate.
ª 2015 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier
B.V. All rights reserved.

1. Introduction episodes of vertigo and nystagmus are produced by certain

First described in 1921 by Barany, benign paroxysmal
positional vertigo (BPPV) is a common disorder wherein brief
* Corresponding author at: Al-Ahli Hospital, Ahmed Bin-Ali Street,
P.O. Box 6401, Doha, Qatar. Mobile: +974 55775049.
E-mail address: dr_hanaa1966@yahoo.com (H.H. Elsanadiky).
Peer review under responsibility of Egyptian Society of Ear, Nose,
Throat and Allied Sciences.
http://dx.doi.org/10.1016/j.ejenta.2015.05.004
2090-0740 ª 2015 Egyptian Society of Ear, Nose, Throat and Allied Sciences. Production and hosting by Elsevier B.V. All rights reserved.
changes of head position relative to gravity.1
At least half of BPPV cases are idiopathic and most patho-
logical associations provide no clue as to the reason why oto-
conia becomes dislodged.2 BPPV may develop secondary to
any of the inner ear diseases (e.g., vestibular neuritis,
labyrinthitis, and Meniere’s disease) that give rise to degenera-
tion and detachment of the otoconia, but do not totally impair
semicircular canal function.3 Several other factors have been
proposed as etiological factors for BPPV including: head
162
trauma, circumstances in which the head is placed or main-
tained in an persistent inverted orientation (e.g., dental proce-
dures, visits to the hairdresser, prolonged travels), migraine
disease, and upper respiratory infection. BPPV may present
bilaterally in 7.5–15% of cases.4,5
Although it has been historically commonplace to reassure
patients diagnosed with BPPV that their condition is benign
and is likely to spontaneously remit in the subsequent months,
recent relatively high quality evidence supports active, expedi-
tious treatment with particle repositioning maneuvers
(PRMs).6
The aim of this study is to prospectively analyze the profiles
of patients who were diagnosed with posterior semicircular
canal (PSC) BPPV with special emphasis on their clinical pre-
sentation and the response to the PRMs.
2. Material and methods
A consecutive series of patients who were clinically diagnosed
with BPPV at Al Ahli Hospital, Doha, Qatar between January
2009 and October 2011 was prospectively studied. Patients
with history of brief vertigo provoked by changes in head posi-
tion and associated with vertigo and nystagmus during the
Dix–Hallpike test on physical examination were included in
this study. The involvement of the posterior semicircular canal
was confirmed during Dix–Hallpike test by the presence of
geotropic up beating torsional nystagmus with its characteris-
tic latency, duration, and fatigability and associated with the
subjective perception of vertigo. Dix–Hallpike test was per-
formed bilaterally. If characteristic findings of BPPV were
identified bilaterally, the amplitude and frequency of nystag-
mus were compared. Eye movements were recorded by
Micromedical two-channel visual eyes using standard test pro-
tocol of visual and vestibular stimulation. Patients with atypi-
cal clinical presentation with positive Dix–Hallpike test were
excluded. In some elderly patients, we performed side lying
test. A thorough evaluation was performed to rule out any
neurological or otological pathology. This included: evalua-
tion of spontaneous nystagmus, head thrust test, other posi-
tional maneuvers, Romberg test and audiological evaluation.
Videonystagmography was only performed when the history
and clinical findings raised the suspicion of an additional
vestibular pathology.
Patients were treated using the Canalith repositioning pro-
cedure (CRP) described by Epley. Patients who experienced
severe vertigo and cannot tolerate head movement were ini-
tially given a 3 day treatment with Betahistine hydrochloride.
Patients were re-evaluated at 3–5 day interval to assess the
response to treatment. CRP was repeated until successful repo-
sitioning had been achieved. In bilateral BPPV, the selection of
the side for initiation of CRM was based on comparison of the
observed nystagmus. The side in which nystagmus was of
higher amplitude, faster or associated with more intensive sub-
jective vertigo was selected for repositioning (Scheme 1).
Treatment success was judged as complete relief of the symp-
toms of vertigo and conversion to a negative Dix–Hallpike test
on physical examination. If the less affected side is still positive
for Dix–Hallpike test we started to do CRP. BPPV was consid-
ered persistent if it did not respond to three sessions of CRP
within two weeks of initial presentation. Recurrence was con-
sidered if positional vertigo developed after at least 2 weeks of
H.H. Elsanadiky, Y.A. Nour
a symptom-free interval following previous successful treat-
ments. All patients were instructed to return if vertigo redevel-
oped. All patients were instructed to perform Brandt–Daroff
exercises at home, starting 2 days after successful
repositioning and for a period of 2 weeks. Patients were
re-examined 3 months and 6 months after testing negatively
for vertigo. Patients were instructed to contact us if they
redevelop positional induced vertigo in the future. In addition,
an attempt was done to contact patients every six months to
inquire about the recurrence of the condition. Only patients with
a minimum of 2 years follow up were included in the study.
Data were analyzed using SPSS software (Statistical
Package for the Social Sciences, version 11.0, SPSS Inc.,
Chicago, IL, USA). Variables were expressed as numbers
and percentages; continuous data were expressed as
mean ± standard deviation. Fisher’s exact test and logistic
regression tests were used for comparisons.
3. Results
A total of 220 patients diagnosed were included in this study
(Table 1). There were 123 females and 97 males with an age
range of 19–73 years (mean age 44.3 ± 11.2 years). Duration
of symptoms before diagnosis ranged from 2 to 28 days. 164
patients (74.5%) presented as the first BPPV episode, whereas
56 (25.5%) presented with recurring episodes. 93 patients
(42.3%) gave a history of visiting general practitioners or
emergency departments before consulting a specialist. The
cause of the BPPV in the study population was presumed to
be related to trauma in 41 patients (18.6%), peripheral vestibu-
lopathy in 20 (9.1%), and it was idiopathic in 159 (72.3%).
Female outnumbered males in the idiopathic group (2:1).
The history of trauma within one week preceding the presenta-
tion was statistically more significant within the bilateral group
(P = 0.0153). In 20 patients with peripheral vestibulopathy,
unilateral sensorineural hearing loss associated with canal
paresis was suggestive of underlying Meniere’s disease in 7
patients. The remaining 13 patients gave a history suggestive
of vestibular neuritis within 6 months prior to the presenta-
tion. The diagnosis was confirmed by the presence of canal
paresis associated with normal cochlear functions. Review of
the history revealed the diagnosis of migraine in 32 patients
(14.5%) according to the criteria of international headache
society. The statement of the patient regarding the direction
of movement that precipitated the majority of attacks corre-
lates with the involved ear in 123 patients (55.9%).
After reviewing the medical records of such patients, cor-
rect diagnosis was done in only 27 patients (29%). The remain-
ing 66 patients were given nonspecific treatment with no
improvement for an average period of 16 ± 5.3 days. Among
the group of 127 patients who consulted specialists, incorrect
diagnosis and non-specific treatment were reported in 43
patients (34%). The percentage of incorrect diagnosis and
the delay in treatment was statistically more significant in the
group of patients who initially consulted non-specialized
physicians (P < 0.0001) (Table 2). Unilateral PSC BPPV was
identified in 148 patients (67.3%). The right PSC was involved
in 87 patients, the left canal in 61 patients and bilateral
involvement was diagnosed in 72 patients (32.7%). In the
patients with bilateral BPPV, symmetrical nystagmus was
reported in 45 patients and the remaining 27 patients had
Diagnosis and management of posterior SCC 163

BPPV

Unilateral Bilateral

Severe

CRM Betaserc CRM (more severe side)

One session or More One session or more

CRM (other side)

Relieve of Symptoms

Brandt- Daroff Exercises

Scheme 1 Scheme for treatment of BPPV.

Table 1 Descriptive table for BPPV patients. Table 3 Type of presentation and bilateral BPPV patients.
Age: Etiology: Type of Typical rotatory Atypical sense of
 Range: 19–73 years  Trauma: 41(18.6%) presentation vertigo with dizziness or
 Mean: 44.3 ± 11.2 year  Peripheral vestibulopathy: evident positional disequilibrium
Sex: 20 (9.1%) trigger without an evident
 Male: 97 (48.5%)  Idiopathic: 159 (72.3%). positional trigger
 Female: 123 (51.5%) Number of 151/220 (68.6%) 69/220 (31.4%) 0.0199
Presentation: patients
 First presentation: 164 (74.5%) Age 110 (50%) 39 (17.5%)
 Recurring Episodes: 56 (25.5%) <50 years
Age 41 (18.6%) 30 (13.5%)
>50 years
Bilateral Symmetrical Asymmetrical
Table 2 Comparison of the management of BPPV patients by
involvement nystagmus nystagmus
general practitioner and specialists.
True 38 9 0.0014
Initial First consulting First consulting P value bilateral
presentation ENT/audiology general practitioner BPPV
or neurology or emergency Unilateral 7 18
specialist department mimicking
Number of 127/220 (57.7%) 93/220 (42.3%) <0.0001 bilateral
patients BPPV
Correct 84 (66%) 27 (29%)
diagnosis
Incorrect 43 (34%) 66 (71%)
diagnosis
Unnecessary 37 (29%) 50 (53.8%) 0.0003
mimicking bilateral BPPV. True bilateral BPPV was identified
investigations in 47 patients (21.4%). Asymmetrical nystagmus was statisti-
Duration 9.6 ± 5.7 13.6 ± 6.5 <0.0001 cally more significant in the group with unilateral mimicking
before bilateral BPPV (P = 0.0014) (Table 3).
diagnosis The correlation was statistically significant in unilateral
PSC BPPV in comparison with the bilateral cases who usually
reported nonspecific head movements as triggers for their
vertigo (P < 0.0001). Among the 173 patients with unilateral
asymmetrical nystagmus. Following successful CRM for the BPPV, 94 patients (54%) identified a predominant sleeping
side with the most prominent nystagmus, re-evaluation did position. The association between affected ear and the head
not reveal nystagmus or subjective vertigo on the contralateral lying side during sleep was statistically significant
side in 25 patients with initial diagnosis of bilateral BPPV. The (P = 0.0034). 103 patients (46.7%) reported sleeping using
diagnosis in those 25 patients was revised as unilateral BPPV only one pillow.
164
Thirty-two patients were severely disabled by the vertigo
and could not tolerate immediate CRP. They were given med-
ical treatment with labyrinthine sedative (Betahistine
hydrochloride 16 mg three times a day) followed by re-
evaluation after 3 days.
Of the 220 patients, 185 (84%) were considered free of
symptoms and converted to negative Dix–Hallpike test after
CRPs. In 113 patients, treatment was successful after one repo-
sitioning session. In the remaining 72 patients, two to four
repositioning sessions (average = 3 sessions) were performed
till full recovery. 35 patients (15.9%) were considered refrac-
tory to positioning maneuvers and subsequent evaluation iden-
tified an underlying peripheral vestibular pathology in 13
patients and they were given vestibular suppressant medica-
tions. Migraine was a potential cause of persistent BPPV in
14 patients who reported improvement of their symptoms after
starting a prophylactic therapy with Betahistine hydrochloride.
In the remaining eight patients, no underlying cause for the
persistent vestibular dysfunction could be identified. They
reported partial improvement of their symptoms by vestibular
rehabilitation exercises. During the follow up period, 48
patients out of the one 185 patients (25.9%) who showed com-
plete initial recovery developed recurrence of symptoms.
Recurrence was statistically significant in patients with trau-
matic etiology, underlying vestibular pathology, bilateral
BPPV at the initial presentation, those with migraine and in
women older than 60 years. 97 patients reported compliance
to instructions regarding Brandt–Daroff exercises for 2 weeks
following repositioning maneuver. Recurrence in this group
of patient was statistically lower than those who were non-
compliant to the exercises (P = 0.011). Recurrence was
reported in the contralateral side in 11 patients.
4. Discussion
BPPV is probably the most common cause of vestibular ver-
tigo accounting for approximately 20–30% of diagnoses in
specialized dizziness clinics with an overall lifetime prevalence
of 2.4%.7–9 However, in spite of the previously published diag-
nostic and therapeutic recommendations, there is still a signif-
icant delay between the initial presentation and the start of
successful treatment with the resultant substantial psychoso-
cial and economic consequences. The delay in diagnosis may
be attributed to the lack of physician awareness of the condi-
tion. In one study, 77% of patients who were finally diagnosed
with BPPV underwent unnecessary testing (e.g., MRI, EEG)
whereas, diagnostic repositioning tests were performed in only
27%. Furthermore, another study showed that most individu-
als presenting with BPPV to a physician either received no
treatment (45%) or non-specific medication for vertigo
(27%) whereas only 10% were treated with positioning maneu-
vers, mostly Brandt–Daroff exercises.9 Therefore, training of
primary care physicians and emergency room doctors; who
are first consulted by patients suffering from vertigo, about
the clinical characteristics and diagnostic positional testing
for BPPV will avoid the delay in diagnosis and unnecessary
interventions. Similarly, improvement of the competence of
the specialist for otorhinolaryngology and neurology with
regard to the diagnosis and treatment of BPPV will definitely
increase the chance of performing the effective repositioning
maneuvers rather than prescribing non-specific symptomatic
H.H. Elsanadiky, Y.A. Nour
medications. The delay in diagnosis may be also attributed
to the atypical presentation of BPPV. A study by Kentala
and Pyykko reported that 80% of patients experience a rota-
tory vertigo and 47% experience a floating sensation.10
Atypical presentation of BPPV in this study was commonly
reported in elderly patients who usually described postural
dizzy symptoms or falling tendency rather than the classical
rotatory vertigo. A high index of suspicion is required in this
group of patients who usually suffer from concomitant cardio-
vascular and neurological comorbidities that further prevent
the correct diagnosis.
Cupulolithiasis and Canalilithiasis represent the main
pathological explanations for BPPV.11,12 This is an oversimpli-
fication of an actual complex condition. Several ultrastructural
studies identified defects in one or more step involved in otoco-
nia metabolism as potential triggers for BPPV. These include
either disorders of otoconia biomineralization or of otoconia
adherence to the otolith membrane.13 Epidemiological studies
often make reference to post traumatic and concomitant
vestibular pathology as the main triggers for otoconial dis-
lodgement. Most of our patients have Canalithiasis, we used
CRP recommended by Epley in all patients even those patients
with Cupulolithiasis. According to the previous literature,
Casqueiro et al., emphasized that repositioning treatment
appears to be efficacious, regardless of minor differences
among maneuvers.14 If the head is moved in appropriate
motion, and rapidly enough approximately 55/s to75/s,15
the treatment is likely to be effective. The minor variation in
technique may not substantially influence the outcome.
Patients who developed anterior horizontal canal BPPV are
excluded. The remaining subgroup of patients without an iden-
tifiable etiology for their symptoms is often cited as having
idiopathic BPPV. Several studies suggest a contributing role
for hormonal, autoimmunity, and degenerative factors in the
etiology of BPPV.16,17 Recently, migraine has also been pro-
posed to be closely associated with BPPV. Migraine was diag-
nosed in 14.5% of our patients. Another study reported the
strongest association for BPPV with migraine; 21% of men
and 43% of women with BPPV had a history of migraine.11
Vasospasm of the labyrinthine arteries is a further putative
mechanism linking BPPV and migraine. Vasospasm of the
labyrinthine arteries may change the regional blood flow of
the inner ear resulting in the release of otoliths.18,19
Abnormalities of central processing in the brainstem or
vestibulocerebellar pathways were postulated by other authors
as the cause of recurrent episodic vertigo in migraineurs.20
Furthermore, diabetes, hypertension, hyperlipidemia and ver-
tebrobasilar ischemia were also suggested as predisposing fac-
tor for BPPV. This was attributed to labyrinthine ischemia
that probably facilitates detachment of otoconia from the oto-
lith membrane.11 However; well-designed controlled studies
are still required to confirm that the association between
BPPV and various systemic pathologies is a causal relationship
and not just a coincidence.
There are particular characteristics of the clinical course and
natural history of BPPV that support the hypothesis of an
underlying systemic pathology. First, true bilateral simultane-
ous BPPV was previously reported in the literature. Blunt
trauma to the head or the cervical spine that might affect both
temporal bones, is commonly attributed as the main etiological
factor for bilateral BPPV.21 In this study, bilateral BPPV was
reported in 21.4% of patients with only 32% of the patients
Diagnosis and management of posterior SCC
giving a history of trauma prior to the onset of their symptoms.
This should raise the suspicion of other contributing factors.
Second, BPPV is a recurring disease. Short term recurrence
rates range from 7% to 23% within a year of treatment, but
long term recurrences may approach 50%, depending on the
age of the patient.22 The potential for contralateral involve-
ment was also demonstrated by a recent study in which 5%
of patients developed contralateral symptoms and signs sug-
gestive of revealed or incipient posterior canal BPPV within
2 weeks of performing Epley’s Maneuver to the ipsilateral
ear. They postulated that incipient disease in the vestibule of
the contralateral ear may be deposited to the posterior semicir-
cular canal, by the reciprocal movements necessary to clear
particles from the first ear.23 Recurrence was reported in the
contralateral ear in 11 patients in this study. Therefore, bilat-
eral BPPV developing either simultaneously or subsequently
in the contralateral ear might be due to an underlying
pathology that is affecting both ears. The time interval
between both ears might represent the duration required for
accumulation of optimum amount of otoconia. It has been
shown by means of physicomathematical models that there
should be approximately 62 otoconia within the semicircular
canal. These particles need further time to agglomerate in
order to exert a hydrodynamic effect when moving in the
canal.24 Therefore, patients with initial bilateral involvement
and those who developed multiple recurrences especially if
involving the contralateral ear require special attention. A
thorough evaluation for an underlying comorbid condition is
mandatory as its treatment might affect the long term control
of BPPV.
The sleeping posture is an important determinant of the
involved ear. In this series the right ear was involved more fre-
quently and there was statistically significant correlation with
sleeping on the right side. This was previously documented
by several studies.25,26 Sleeping on one pillow is another
important finding in our patients. This relatively low head
position during sleep would place the posterior canal in a more
dependent position allowing the otoconia to fall deeper within
the canal by the effect of gravitational force. Such finding sup-
ports the previous recommendation that remaining upright for
one night weekly by raising the pillows is so effective in pre-
venting the recurrence of BPPV. This upright position will
maintain a horizontal plan of the utricle and maximize the
probability that the extra otoconia will land upon the surface
of the dark cells of the otolith membrane rather than entering
the semicircular canals.15 According to Li et al. patients sleep-
ing on their affected side had a higher recurrence rate than
those sleeping in other positions at one week after the reposi-
tioning maneuver. They concluded that BPPV patients should
be advised to refrain from sleeping on their affected side for at
least one week after the repositioning maneuver.27
There is a general agreement that vestibular suppressant
medications are not recommended for the routine treatment
of BPPV, other than for the short-term management of vege-
tative symptoms such as nausea or vomiting in a severely
symptomatic patients.28,29 In the present study, we prescribed
betahistine for patients with severe attacks who cannot tolerate
head movement. Recent studies showed that betahistine in
addition to CRP is more effective than CRP alone or com-
bined with placebo with regard to improvement of symptoms.
It was assumed that after removing the otoconia, betahistine
plays an important role for improving blood flow in the inner
165
ear with the resultant restoration of the normal function of
motion-sensitive hairs cells and stabilization of the posture.30
There is little controversy regarding the role of PRMs in the
management of BPPV. The selection of CRP was based on
previous recommendations that it is an effective and safe ther-
apy that should be offered to patients of all ages with posterior
semicircular canal BPPV. Although many experts believe that
the Semont’s maneuver is as effective as PRM, based on cur-
rently published articles the Semont’s maneuver can only be
classified as ‘‘possibly effective and there is insufficient evi-
dence to establish the relative efficacy of the Semont’s maneu-
ver to CRP.21
Brandt–Daroff exercises which were designed to habituate
symptoms. The patient moved from sitting at the edge of the
bed to lying on side (side lying) with the head rotated 45
toward the ceiling. The patient alternated between left side
lying and right side lying.31 Helene reported that modifying
the CRM, performing CRM plus a home program, or having
involvement of second semicircular canal does not change
treatment effectiveness.32 A Previous study supports this find-
ing, however they recommended, the clinician could use CRM
in the office and the give a home exercise for use initially in
case of recurrrence.33 On the other hand, Tanimto et al. found
that CRM, alone, was less effective than CRM plus home
excrercises.34
5. Conclusion
Canalith Repositioning Maneuver described by Epley is effec-
tive in treatment of posterior semicircular Canal Benign
Paroxysmal Positional vertigo. Our study recommended the
use of step wise flow-chart for diagnosis and management of
patients with unilateral or bilateral posterior canal BPPV.
Patients with bilateral BPPV are not all true, some cases are
unilateral BPPV mimic bilateral BPPV which relieved after
Epley Maneuver to severer side. In addition, daily routine
Brandt–Daroff exercises decrease the recurrence rate.
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