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Benign paroxysmal positional vertigo (BPPV): A balance disorder that results in the sudden onset of dizziness, spinning, or vertigo when moving the head. If you experience vertigo turning your head, lying down and rolling in bed you may have BPPV. Anterior canal BPPV is probably very rare because the anterior canal is the highest part of the ear. The Dix-Hallpike maneuver diagnoses both posterior canal BPPV as well as contralateral anterior canal BPPV. The conventional (loose) criteria for AC-BPPV are a supine-position triggered DBN, with or without torsion. AC BPPV is almost certainly grossly over diagnosed, as the patterns of nystagmus attributed to AC BPPV by most clinicians make no sense. Furthermore, in AC BPPV, considering the physiology, there also should be an upbeating nystagmus on reassuming upright as well as a low level UBN all the time.
AC BPPV is supposedly diagnosed by a positional nystagmus with components of downbeating and (sometimes) torsional movement on taking up the Dix-Hallpike position (shown above). Ipsitorsion purely due to excitation of the down ear is not anatomically possible as all methods of producing DBN on the down side (excitation of AC, inhibition of PC) produce torsion in the other direction. A more plausible way to organize this would be to postulate two separate mechanisms for DBN and torsion -- for example, it might reasonably be due to a mixture of a pure DBN, perhaps due to saccular damage or cerebellar damage, and an ordinary PC BPPV. Anterior canal BPPV, especially when there is no torsional component, has a much wider differential than posterior canal (PC) BPPV, as it includes the numerous other causes of downbeating nystagmus.
Just a year later, Kim and associates (2005) described a more logical treatment maneuver for the anterior canal. The Kim maneuver is fairly logical, but it could be more logical- -in particular, position 'c' debris close to the cupula might not move around the turn. Yacovino, Hain and Gualtieri (2009) reported results of using a maneuver similar to that of Kim in 13 patients. For all of the supine AC BPPV maneuvers, there is a problem in that they may be physically impossible due to neck flexibility. This procedure is essentially the positioning of Crevit's maneuver, without the 24 hours of immobilization. At this writing (2009), home treatment of AC BPPV has not been studied (unlike the case for PC BPPV).
We, like Hetzler (2007) are unenthused about using the conventional Epley or Semont maneuvers to treat clear cut AC-BPPV (e.g. Because anterior canal BPPV is more complex than posterior canal BPPV, and includes far more central nervous system conditions (i.e. Naples JG, Eisen MD Surgical management for benign paroxysmal positional vertigo of the superior semicircular canal.
Debris would naturally tend to fall out of the posterior half of the anterior canal, and getting debris into the anterior canal would not be easy. Flourens, Ewald), nystagmus from the inner ear is mainly oriented in the plane of the stimulated canal. In our very large experience with BPPV, while DBN supine is very common, especially with ipsi-torsion, UBN upright is rare. While people that fit the loose (illogical) criteria are common, almost nobody fits the strict (logical) criteria, and it may be that the whole syndrome is a misnomer. These laws express the general idea that the eyes move in the plane of the canals being stimulated. To be paired with DBN, this vector would have to be due to inhibition of the contralateral PC.

Cambi et al, 2013), the origin is probably not BPPV of any type, as there is an intrinsic pairing between stimulation of the canals and a mixed torsion-vertical nystagmus.
One should be considering other possible explanations - -especially cerebellar lesions, in persons with nystagmus attributed to AC-BPPV.
This idea allows for the appearance of DBN after treatment for PC BPPV, without attributing it to AC BPPV. Thus, even though things might appear complex below, in essence, all of these maneuvers are just trying to get the person upside down, let the debris fall to the top of the canal, and then put them into a position where it will continue around the circle and go backwards into the vestibule.
In other words, our thought is that the response rate of maneuvers for supine DBN is low -- perhaps < 50%, and that this is basically due to the lack of a clear cut method of diagnosing AC-BPPV. In this procedure, there is an attempt to bring the head backwards as far as possible -- 60 degrees beyond supine, (in theory, upside down would be best), followed by return to upright and immobilization of the head in this position for 24 hours. Also, if one accepts the idea that the most anterior part of the AC is nearly saggital, one should logically start this maneuver with deeper head-hanging to get that segment upside down, then go to the head 40 degrees to the symptomatic side. This again was an uncontrolled study, and the diagnostic criteria for AC BPPV were not as tight as suggested above (criteria were supine DBN with or without torsion). In this maneuver, the patient is prone on a table, with the head over the end and bent forward off the end of the table, as if one was looking for a piece of gum under the mat table. This can be performed on a mat table, or if necessary, using a tilt table or similar gadget that can turn the patient upside down (e.g. Management of 210 patients with benign paroxysmal positional vertigo: AMC protocol and outcomes.
Posterior semicircular canal benign paroxysmal positional vertigo presenting with torsional downbeating nystagmus: an apogeotropic variant.
This type of BPPV is thought to be characterized by down-beating nystagmus (DBN) on lying flat, and upbeating nystagmus (UBN) on reassuming upright position. From the geometry of the ear, it would seem likely that anterior canal BPPV might occasionally result as a complication of the Epley maneuver.
It seems to us that these statistics might depend on how the clinics treat their posterior canal BPPV, as some treatment protocols might tend to be incomplete and result in more of the common-crus type BPPV than others. As the contralateral PC is horizontal during the Dix-Hallpike to the ipsilateral side, this would seem improbable, but nevertheless still within the realm of possibility, especially if one allows for the possibility of canals that are not entirely in one plane. One would expect for this situation that the timing of the two components would differ - -i.e. See this link for a case of a person who was thought to have AC-BPPV, but actually had a brain tumor. Should debris on either the short arm of the PC (this location seems reasonable) or long arm of the AC (this location seems unlikely), it could load down the cupula and cause a tonic UBN. These maneuvers, starting with nose down to the side that makes the AC vertical, are at least somewhat logical, but their biomechanics are not as good as ones where the head is literally upside-down, as for the Kim or Yacovino maneuvers discussed below.
This maneuver does not make much sense, as in at least one of the two positions, the AC must be horizontal, and we don't think it is currently in use today. In our opinion, the positions of this maneuver are reasonable, but the rationale for 24 hours of immobilization of the head is difficult to comprehend.
Note that the illustrations of the canals from the Kim article (shown above) are anatomically impossible artists renditions. This treatment differs from that of Kim (above) in that the head is not turned to either side, and it is positioned so that it is further back with respect to horizontal in position 2. Note that the illustrations of the canal anatomy taken from the Kim paper (see above) are not anatomically correct -- you should use an actual physical model of the semicircular canals to work this out for yourself.
In persons who don't spend a lot of time upside down, other than perhaps Yoga enthusiasts, it is difficult to imagine a plausible mechanism otherwise.

We generally agree with this idea and we have also encountered a few patients who ONLY have nystagmus in the head-hanging position (but this doesn't prove that it is due to AC BPPV).
After a maneuver that moved debris out of either place, such as an Epley maneuver, there could be a DBN that had built up to counteract the peripheral UBN, via central adaptation. We think it is interesting that there is no controlled study of AC treatment at this writing (2014). We find this very difficult to believe, as nothing is ever this good, and there are some other issues (see end of paragraph below), but still the authors seem to be enthused about the maneuver, and maybe it works. As is the case for uncontrolled studies in general that seem to violate common sense and conventional experience -- like this one -- perhaps this study is simply overly enthusiastic. From the discussion above, other potential mechanisms than AC BPPV include long-arm PC BPPV, and central adaptation nystagmus.
These are generally inaccessible, and thus it seems prudent to think about how to attain an upside down position, without a specialized machine. After a reasonable length of time (perhaps based on how long the downbeating nystagmus persists), one is flipped onto the back so that the debris falls towards the vestibule. It does not seem to us that the added effort of getting the patient upside down, is rewarded by a higher cure rate.
The geometry of the AC is such that one would expect these maneuvers could even make it worse, because they involve nose-down positioning.
On the other hand, the anterior canal as a whole is not at all aligned with the sagittal plane -- it is about 40 degrees away (Della Santina et al, 2005). It would seem to us unlikely that someone who clearly has dizziness from their ear, would have a central nystagmus either. The rules for central nystagmus are not the same as peripheral nystagmus, they don't have to be in canal planes, and a purely DBN is conceivable.
The studies published to date, not only are uncontrolled, but also use loose diagnostic criteria.
Squires et al, 2004) as well as from experience with other types of BPPV that, at most, debris moves in minutes. The maneuver in this study, like that of Kim, while designed for AC-BPPV, might also be effective for PC BPPV of any variety as prolonged inversion might move debris from close to the cupula to a position near the common crus for the PC.
This maneuver (so far unaccompanied by any clinical trial) may be the most reasonable for older patients where the head may be anteriorly positioned due to kyphosis.
Just because part of the canal is sagittal, does not mean that stimulation of the canal should cause purely vertical nystagmus in one segment, and mixed in another. This logic suggests that a supine DBN that follows a successful Epley maneuver might not be AC BPPV, but rather might be central DBN.
Also, the results of Kim (2005) and Yacovino (2009) see below, in a much shorter time, suggest that prolonged positions are not needed. No study is yet available - -but as the geometry is identical as all of the other maneuvers, it seems likely to have similar results. If there is both ipsitorsion and DBN, perhaps a mixture of residual PC BPPV and central DBN.

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10.04.2014, author: admin

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