Question
What is the recommened treatment for BPPV in the anterior canal? I believe I have a pt. that is positive for BPPV in this canal. Pt. has classic BPPV signs. However, the nystagmus is rotary and downbeating not upbeating. The classic CRP did not relieve the pt. of the BPPV which made me look again at the nystagmus. Please respond as soon as you can. I see the patient back tomorrow afternoon.
Answer
I have to answer this question from two different perspectives. The first, my personal observations; and the second, a review of the limited literature on anterior canal BPPV.
Personally, I am not sure that I have seen an anterior canal BPPV (amongst thousands of posterior canal versions). Therefore, I use a modified Epley maneuver for most cases of BPPV, unless it is a horizontal canal variant. I have noted that if I get a response to the Dix-Hallpike where the direction of rotary nystagmus is opposite what one would expect, frequently I will get a classic stronger response to the Dix-Hallpike on the opposite side. Does this mean that the reversed nystagmus are the result of free flowing otoconia moving towards the ampulla in the posterior canal of the opposite side? I am not sure, but CRP on the opposite classis response side almost always alleviates the symptoms.
The literature on the subject suggests using the exact same CRP procedure you would use for posterior canal BPPV. Keep in mind that a Left Dix-Hallpike would elicit a response from the Right anterior canal. Treat this the same as you would a Left posterior canal canalithiasis. A recent (May 2004) article in the Journal of Neurology, Neurosurgery and Psychiatry by L Crevits offers a specific procedure for anterior canal BPPV. It is called the prolonged forced position procedure, and requires the patient to remain lying in a recommended position for several hours. I have not tried it, and, thank goodness, have not needed to try it.
Alan Desmond, Au.D is the director of Blue Ridge Hearing and Balance Clinic in Bluefield and Princeton, WV. Thieme Medical Publishers released his book Vestibular Function: Evaluation and Treatment in April 2004. He can be reached at BRHBC@comcast.net