Benign paroxysmal positional vertigo predominantly affects the right labyrinth

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  1. Yard von Brevern1,
  2. T Seelig1,
  3. H Neuhauser2,
  4. T Lempert3
  1. 1Neurologische Klinik, Charité, Campus Virchow-Klinikum, Berlin, Germany
  2. 2Robert-Koch-Institut, Berlin, Deutschland
  3. 3Neurologische Abteilung, Schlosspark-Klinik, Berlin, Germany
  1. Correspondence to:
 Dr M von Brevern michael.von_breverncharite.de

Abstract

Benign paroxysmal positional vertigo (BPPV) occurs when at that place are freely moving particles in a semicircular canal and the head is turned in the airplane of the affected canal. The aim of the present study was to clarify whether BPPV manifests equally in both labyrinths or whether in that location is a preponderance for i side. We conducted a PubMed literature search of BPPV case series which specified the affected side and a retrospective chart review of 80 sequent patients with BPPV of the posterior canal who had presented at our dizziness clinic.

18 studies with a full of 3426 patients were identified. In our ain series the right side was affected in 54 of fourscore patients (right/left ratio 2.08). Altogether, in 3506 patients the right labyrinth was involved ane.41 times more oft than the left (95% CI 1.37 to 1.45). We think that the reason for the predominant involvement of the right ear in BPPV is the habit—of most patients—of sleeping on the right side.

  • BPPV, beneficial paroxysmal positional vertigo
  • beneficial paroxysmal positional vertigo
  • utricle
  • canalolithiasis
  • otoconia

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  • BPPV, beneficial paroxysmal positional vertigo
  • benign paroxysmal positional vertigo
  • utricle
  • canalolithiasis
  • otoconia

Benign paroxysmal positional vertigo (BPPV) is the commonest vestibular disorder, accounting for about twenty% of referrals in specialist dizziness clinics. According to the widely accepted canalolithiasis theory it is caused past mobile particles with density higher than that of the endolymph that take entered a semicircular canal of the vestibular organ.ane These particles motion freely within the endolymph of the afflicted culvert and tend to settle downward in the nearly dependent location. A modify in the position of the caput in the plane of the affected culvert causes the particles in the canal to move resulting in abnormal hydrodynamic forces upon the cupula. In that location is show that the particles consist of dislodged otoconia from the utricle.2

Theoretically, i would expect that this pathology affects both ears equally. So far this has not been systematically investigated and the aim of the present report was to clarify whether BPPV involves one ear more than often than the other.

METHODS

The PubMed database was searched from 1966 to Dec 2002 to identify instance series of patients with BPPV. Only those studies were selected which included more than 20 patients with unilateral BPPV and specified the afflicted side. Another requirement was confirmation of the diagnosis by ascertainment of typical nystagmus during a provocative manoeuvre. Those studies which exclusively included patients with BPPV of the horizontal canal were excluded.

In addition, a retrospective chart review was conducted to identify the affected side in all patients with unilateral BPPV of the posterior culvert who had presented to our dizziness dispensary betwixt January 2001 and September 2003.

RESULTS

The PubMed search yielded 18 case series which specified the side afflicted by BPPV in a full of 3426 patients (table 1).3– 20 The correct ear was affected in 1999 patients and the left in 1427, thus the right ear was involved 1.40 times more ofttimes than the left. Only two of 18 studies described more patients with BPPV on the left than on the right side.5, nine Of fourscore patients presenting to our dizziness clinic with unilateral BPPV of the posterior canal, 54 had the right ear affected (correct/left ratio 2.08). Altogether, in the 3506 patients included in this study the right labyrinth was affected one.41 times more often than the left (95% CI i.37 to i.45).

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Tabular array one

 Laterality of ear affected by benign paroxysmal positional vertigo (BPPV) in 18 studies reported in the literature and patients presenting to the dizziness dispensary

Word

According to the canalolithiasis theory typical BPPV of the posterior culvert is caused by otoconia that dislodge from the utricle and enter the semicircular canal where they move freely within the endolymph.one This theory explains all features of BPPV and has been corroborated past the finding of dense particulate matter, free floating in the endolymph of the posterior canal of patients with BPPV.ii It is now known that BPPV develops in stages: first the otoconia detach from the utricular matrix, and and so they enter into a semicircular canal when the head assumes a critical position. Furthermore, it has been shown by means of physiomathematical models that the prerequisites for BPPV are: (i) at that place should exist approximately 62 otoconia within the semicircular canal and (ii) these particles accept to agglomerate in club to exert a hydrodynamic effect when moving in the canal.21

Our written report shows that the correct ear is predominantly affected by BPPV. How can this predilection be explained on the basis of the canalolithiasis model? There are five factors which obviously predispose to BPPV: trauma to the head, other ear disease, advanced age, migraine, and bed residue.22, 23 The first four factors probably account for the detachment of otoconia from the utricle by mechanical ways or degenerative and ischaemic changes, just it seems unlikely that one ear is affected more than frequently by ane of these mechanisms than the other. About studies included patients with both idiopathic and secondary BPPV. 1 case series also showed a preponderance of right sided BPPV in a group of patients with secondary BPPV due to inner ear disease.10 Prolonged bed residual probably facilitates agglomeration of otoconia, but again, this should utilise equally to both labyrinths.

Since damage to the utricle and agglomeration of otoconia are unlikely reasons for the predominance of the correct side, we doubtable that the critical mechanism occurs in the concluding phase in the pathophysiology of BPPV: the entry of particles into a semicircular canal depending on the position of the head.

Interestingly, slumber seems to exist involved in the pathophysiology of BPPV and many patients experience their starting time attack when moving in bed after enkindling.12 Recently, it has been shown that the side affected by BPPV correlates with the preferred position in bed: in 33 of 45 patients with BPPV of the posterior canal the side of the involved semicircular culvert was the side patients used to prevarication on. Near patients slept in the right supine position and had BPPV on the right.13 Freely moving otoconia in the labyrinth have a higher density than endolymph and follow gravity. In the correct lateral supine position the openings of both the right posterior and the horizontal canals are in the lowermost position, which facilitates entry of heavy particles from the utricle. Thus one might speculate that BPPV predominantly involves the right ear because many persons prefer to sleep on the right side, possibly due to an uncomfortable awareness of the heart beat when lying on the left side. Positions during sleep have received little scientific attention, but it is known that patients with congestive heart failure spend significantly more time on the correct than on the left side during sleep, whereas subjects without heart disease lie for an equally long time in both lateral positions.24 Every bit near patients with BPPV are of advanced historic period22 when heart failure is a frequent comorbid condition, nosotros propose that a potential factor favoring the occurrence of BPPV on the right side is the preference of the right lateral supine position in bed.

REFERENCES

  1. ↵

    Brandt T , Steddin S. Current view of the mechanisms of benign paroxysmal positioning vertigo: cupulolithiasis or canalolithiasis? J Vestib Res 1993;3:373–82.

  2. ↵

    Welling DB, Parnes LS, O'Brien B, et al. Particulate matter in the posterior semicircular canal. Laryngoscope 1997;107:90–four.

  3. ↵

    Asawavichianginda S , Isipradit P, Snidvongs K, et al. Canalith repositioning for benign paroxysmal positional vertigo: a randomized, controlled trial. Ear Nose Throat J 2000;79:732–7.

  4. ↵

    Blakley BW. A randomized, controlled assessment of the canalith repositioning maneuver. Otolaryngol Head Neck Surg 1994;110:391–half dozen.

  5. ↵

    Brandt T , Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol 1980;106:484–five.

  6. ↵

    Dal T , Özlüolu LN, Ergin NT. The canalith repositioning maneuver in patients with benign positional vertigo. Eur Arch Otorhinolaryngol 2000;257:133–6.

  7. ↵

    Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399–404.

  8. ↵

    Froehling DA, Bowen JM, Mohr DN, et al. The canalith repositioning process for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial. Mayo Clin Proc 2000;75:695–700.

  9. ↵

    Harvey SA, Hain TC, Adamiec LC. Modified liberatory maneuver: constructive treatment for benign paroxysmal positional vertigo. Laryngoscope 1994;104:1206–12.

  10. ↵

    Karlberg M , Hall K, Quickert Northward, et al. What inner ear disease cause benign paroxysmal positional vertigo? Acta Otolaryngol 2000;120:380–five.

  11. ↵

    Katsarkas A . Benign paroxysmal positional vertigo (BPPV): idiopathic versus mail-traumatic. Acta Otolaryngol 1999;119:745–ix.

  12. ↵

    Korres S , Balatsouras DG, Kaberos A, et al. Occurrence of semicircular canal involvement in beneficial paroxysmal positional vertigo. Otol Neurotol 2002;23:926–32.

  13. ↵

    Lopez-Escámez JA, Gámiz MJ, Fiana MG, et al. Position in bed is associated with left or correct location in beneficial paroxysmal positional vertigo of the posterior semicircular canal. Am J Otolaryngol 2002;23:263–half dozen.

  14. ↵

    Marciano E , Marcelli V. Postural restrictions in labyrintholithiasis. Eur Arch Otorhinolaryngol 2002;259:262–five.

  15. ↵

    Nuti D , Nati C, Passali D. Treatment of benign paroxysmal positional vertigo: no need for postmaneuver restrictions. Otolaryngol Head Neck Surg 2000;122:440–four.

  16. ↵

    O'Reilly RC, Elford B, Slater R. Effectiveness of the particle repositioning maneuver in subtypes of beneficial paroxysmal positional vertigo. Laryngoscope 2000;110:1385–8.

  17. ↵

    Sargent EW, Bankaitis AE, Hollenbeak CS, et al. Mastoid oscillation in canalith repositioning for paroxysmal positional vertigo. Otol Neurotol 2001;22:205–9.

  18. ↵

    Serafini K , Palmieri AM, Simincelli C. Beneficial paroxysmal positional vertigo of posterior semicircular canal: results in 160 cases treated with Semont's maneuver. Ann Otol Rhinol Laryngol 1996;105:770–5.

  19. ↵

    Soto Varela A , Bartual Magro J, Santos Pérez S, et al. Beneficial paroxysmal vertigo: a comparative prospective report of Brandt and Daroff exercises, Semont and Epley manoeuvre. Rev Laryngol Otol Rhinol 2001;122:179–83.

  20. ↵

    Wolf JS, Boyev KP, Manokey J, et al. Success of the modified Epley maneuver in treating benign paroxysmal positional vertigo. Laryngoscope 1999;109:900–3.

  21. ↵

    House MG, Honrubia V. Theoretical models for the mechanisms of beneficial paroxysmal positional vertigo. Audiol Neurootol 2003;8:91–nine.

  22. ↵

    Epley JM. Positional vertigo related to semicircular canalithiasis. Otolaryngol Head Neck Surg 1995;112:154–61.

  23. ↵

    Ishiyama A , Jacobson KM, Baloh RW. Migraine and benign positional vertigo. Ann Otol Rhinol Laryngol 2000;109:377–80.

  24. ↵

    Leung RST, Bowman ME, Parker JD, et al. Avoidance of the left lateral decubitus position during sleep in patients with heart failure: relationship to cardiac size and function. J Am Coll Cardiol 2003;41:227–30.

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Copyright 2004 Journal of Neurology Neurosurgery and Psychiatry