Posterior semicircular canal occlusion for benign paroxysmal positional vertigo—CO2 laser-assisted technique: Preliminary results

Benign paroxysmal positional vertigo (BPPV) is a common vestibular end-organ disorder that in the majority of patients resolves with conservative management. In the occasional patient who has unremitting BPPV despite conservative treatment, posterior semicircular canal occlusion (PCO) may be effective in eliminating symptoms. In an attempt to minimize the risk of hearing loss, a modified procedure was developed that uses the CO₂ laser to shrink the membranous vestibular posterior semicircular canal prior to mechanically plugging the canal. Preliminary results of this CO₂ laser-assisted occlusion technique used in four patients are presented.     

Three-dimensional reconstruction and measurement of the human membranous semicircular canal

The planar relationship of the human semicircular canals was determined by Blanks et al. at a series of points measured from the dissected bony labyrinth of the human skull. The relationship of membranous canal planes have not, however, been measured from the human temporal bone. We reconstructed 3 semicircular canals by computer-aided 3-dimensional analysis and measured the angles formed between pairs of 3 osseous and membranous canal planes of temporal bones. Five temporal bones in adults were used for this study. Results indicated angles formed between pairs of ipsi-lateral canal planes of both the bony and membranous labyrinth. Angles formed between the horizontal-anterior, anterior-posterior, and posterior-horizontal canal planes of the bony labyrinth were 89.64 +/- 1.82 (mean +/- SD), 90.95 +/- 1.25, and 94.02 +/- 3.77 degrees. The same angles measured from the membranous labyrinth were 90.12 +/- 2.64, 90.18 +/- 2.75, and 91.48 +/- 6.32 degrees. Differences between the angles formed between bony and membranous canal planes were 2.11, 6.05, and 3.26 degrees in the anterior, horizontal, and posterior canal. Pairs of membranous canal planes were nearly perpendicular without exception, but pairs of osseous canal planes had a larger deviation from 90 degrees. This suggested that membranous canals could successfully be constructed in adequate alignment for canal function in the large perilymphatic space within osseous semicircular canals.     

Non-ampullary plugging of the posterior semicircular canal for benign paroxysmal positional vertigo.

Benign paroxysmal positional vertigo (BPPV) is a common condition which is usually self-limiting. Surgical treatment is rarely required and for many years the mainstay of such treatment has been singular neurectomy (posterior ampullary nerve section). A new operation has recently been described for the treatment of BPPV involving occlusion of the posterior semicircular canal. We have performed this operation on five patients with intractable BPPV and report our results with follow up of between 12 and 36 months from operation. The excellent results of posterior semicircular canal occlusion which have been previously reported in the literature are confirmed by our experience. In our opinion the operation is a safe and effective alternative to singular neurectomy.     

Surgery of the posterior semicircular duct for the treatment of BPPV

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo in the otolaryngology clinic. The liberatory maneuvers are the treatment of choice in this entity. In a low percentage of patients, about 5-10%, we found no response to the maneuvers. The occlusion of the posterior semicircular canal is offered for intractable cases. We report a case of woman with an intractable BPPV in which an occlusion of the posterior semicircular was done. We describe the indications, how to perform the surgery and the functional results of this technique.     

Long-term results of posterior semicircular canal occlusion for intractable benign paroxysmal positional vertigo.

Benign paroxysmal positional vertigo (BPPV) is a common condition which is usually managed conservatively, surgical intervention being recommended only for those small number of patients in whom it becomes persistent and incapacitating. The results of surgery in 13 patients who underwent posterior semicircular canal occlusion for intractable (> 12 months duration) and incapacitating BPPV are presented with special emphasis on their long-term follow-up. The mean follow-up was 66 months (range, 29-119 months). All patients reported complete and immediate resolution of their positional vertigo, which has been maintained in the long term. Most patients, however, reported some postoperative transient unsteadiness which lasted up to 4 weeks. All patients developed a transient mild conductive hearing loss secondary to a middle ear collection, which usually resolved within 4 weeks. Five patients developed a transient mild high frequency sensorineural hearing loss which resolved in all cases within 6 months. There were no reports of sensorineural hearing loss nor tinnitus in the long term. All patients believed that the operation was beneficial and would undergo it again. Our findings indicate that posterior semicircular canal occlusion is an effective and safe operation in the long term and is the procedure of choice for intractable and incapacitating BPPV rather than singular neurectomy.     

Particle repositioning maneuver for benign paroxysmal positional vertigo

The recent demonstration of free-floating particles in the endolymph of the posterior semicircular canal in patients with benign paroxysmal positional vertigo (BPPV)¹ has renewed interest in the physiology and treatment of this entity. The particle repositioning maneuver (PRM) relocates the free-floating particles from the posterior semicircular canal back into the utricle, relieving the patient of bothersome, often long-standing vertigo. This report represents a prospective study of 27 consecutive patients seen with a diagnosis of BPPV. Eighty-four percent of the patients treated with the particle repositioning maneuver who had no other associated pathology were cured or significantly improved with this new technique. Two patients who failed conservative management went on to surgical intervention with the posterior semicircular canal occlusion. The authors find the particle repositioning maneuver effective for many patients with benign positional vertigo and recommend it as the first-line treatment modality for BPPV.     

难治性良性阵发性位置性眩晕的临床分析

目的 探讨难治性良性阵发性位置性眩晕(BPPV)的临床特点及治疗。 方法 回顾分析2014年8月至2016年1月诊断为难治性BPPV的13例患者的临床资料,分析其病因相关因素、类型、临床特点及治疗效果。 结果 13例难治性BPPV中,头部外伤为最常见因素,离地性水平半规管BPPV为最常见类型。根据病因积极治疗伴随疾病,正确手法复位治疗,联合Brandt-Daroff康复训练,11例治愈,随访1年无复发;2例无效;1例后半规管、1例水平半规管BPPV,至他院行半规管堵塞术手术治疗,术后效果好。 结论 难治性BPPV可能与头部外伤及突发性聋等疾病相关,首先需根据病因积极治疗伴随疾病,同时采用正确的手法复位治疗,并联合康复训练。治疗后大部分患者疗效好,无效者行半规管堵塞术效果好。     

Long-term results of posterior semicircular canal occlusion for intractable benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is a common condition which is usually managed conservatively, surgical intervention being recommended only for those small number of patients in whom it becomes persistent and incapacitating. The results of surgery in 13 patients who underwent posterior semicircular canal occlusion for intractable (>12 months duration) and incapacitating BPPV are presented with special emphasis on their long-term follow-up. The mean follow-up was 66 months (range, 29–119 months). All patients reported complete and immediate resolution of their positional vertigo, which has been maintained in the long term. Most patients, however, reported some postoperative transient unsteadiness which lasted up to 4 weeks. All patients developed a transient mild conductive hearing loss secondary to a middle ear collection, which usually resolved within 4 weeks. Five patients developed a transient mild high frequency sensorineural hearing loss which resolved in all cases within 6 months. There were no reports of sensorineural hearing loss nor tinnitus in the long term. All patients believed that the operation was beneficial and would undergo it again. Our findings indicate that posterior semicircular canal occlusion is an effective and safe operation in the long term and is the procedure of choice for intractable and incapacitating BPPV rather than singular neurectomy.     

Surgical management for benign paroxysmal positional vertigo of the superior semicircular canal

Benign paroxysmal positional vertigo of the superior semicircular canal is a rare form of BPPV. It accounts for 1% to 3% of cases. The characteristic nystagmus is positional, down‐beating, with a torsional component elicited by the Dix‐Hallpike maneuver. Symptoms of superior semicircular canal BPPV often resolve spontaneously; however, it can be refractory to repositioning maneuvers. Surgical management is described for posterior semicircular canal BPPV. To date, however, there is only one reported case of surgical management for superior semicircular canal BPPV. Here we show video documentation of positional, down‐beating nystagmus and describe a case of superior semicircular canal BPPV requiring canal occlusion with successful resolution of symptoms. Laryngoscope, 125:1965–1967, 2015     

Free-Floating endolymph particles: A new operative finding during posterior semicircular canal occlusion

Most clinicians accept cupulolithiasis as the pathophysiological mechanism underlying benign paroxysmal positional vertigo (BPPV.) According to this theory, a cupular deposit induces a gravitational effect on the posterior canal crista. Posterior semicircular canal occlusion is a new operative procedure for treating incapacitating BPPV. It is postulated that canal occlusion abolishes endolymph movement within the canal, effectively fixing the cupula and rendering it unresponsive to both angular and linear acceleration (gravity). During two recent canal occlusions, abundant “free-floating particles” were identified within the posterior canal endolymph. When changing the position of the canal in the earth vertical plane, these free-floating particles would move under the influence of gravity. The hydrodynamic drag of the particles would induce endolymph movement with cupular displacement leading to the typical response. This finding supports an alternate explanation to cupulolithiasis as the pathophysiological mechanism underlying BPPV.     

Important factors for the hearing loss caused by the triple semicircular canal occlusion in guinea pigs.

HYPOTHESIS: Dynamic recording of the auditory brainstem response is helpful in verifying harmful procedure(s) to hearing during triple semicircular canal occlusion (TSCO) surgery. The damage to the membranous semicircular labyrinth is the single major contributor to hearing loss caused by TSCO. BACKGROUND: Posterior semicircular canal occlusion has been recognized as an efficient method of eliminating vertigo without causing a significant hearing impairment. Recently, TSCO has also been explored for its potential to treat vertigo of various causes. In limited animal studies, varied hearing impairments have been documented after TSCO. However, the major factor(s) causing hearing loss in TSCO is/are unclear. METHODS: Triple semicircular canal occlusion was performed on 36 guinea pigs in total. The cochlear function of the guinea pigs was monitored by observing the auditory brainstem response. The impact of membranous labyrinth damage on hearing was verified by a between-group comparison. RESULTS: Hearing loss during TSCO was accumulated in every step of semicircular canal manipulation. Generally, perilymph leak was found to cause a slight hearing loss that was predominately recovered during surgery. However, transaction of the membranous labyrinth usually caused a more significant hearing loss that was not recovered during the surgery. In addition, the magnitude of hearing loss seemed to be increased with the elongation of the surgery. However, the hearing can be largely recovered after the surgery even in animals with transaction of the membranous labyrinth. CONCLUSION: Hearing loss caused by TSCO can be greatly reduced by avoiding damage to the membranous labyrinth and by shortening the operation time.     

Laser irradiation of the semicircular canal: occlusion of the canal or duct

The aim of this study was to evaluate the effects of argon laser irradiation of the semicircular canals using computed tomography (CT) images and to examine the basis for laser treatment for benign paroxysmal positional vertigo (BPPV). CT images of the posterior canal were evaluated postoperatively in a patient with intractable BPPV, in whom the unilateral posterior and lateral semicircular canals were irradiated with an argon laser. In addition, bootstrap analysis of 20 patients with normal CT findings of the temporal bone was performed and previous experimentally obtained histologic findings were compared. Cross-sections of the posterior canals of 20 patients were found to show no difference in size between the right and left sides. The laser-irradiated posterior canal became narrower than that on the non-irradiated healthy side in our patient. There was a discrepancy between the CT images and experimentally obtained histologic findings that showed complete occlusion of the canal. CT images of a patient with severe vertigo demonstrated that argon laser irradiation to the blue-lined semicircular canals did not occlude the canal of the corresponding areas, while the canal of the guinea pig histologically showed complete obstruction with new bone after irradiation with the same energy (1.5 W, 0.5 s, spot size: around 200 μm in diameter). The patient has been free from vertigo for 16 years. Marked constriction of the semicircular duct corresponding to the irradiated area appeared to be effective in treating intractable BPPV.     

Diagnosis and management of benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is a common disorder of the vestibular labyrinth which should be suspected in all patients with a history of vertigo during changes of head position. The BPPV appears to be caused by free-floating debris in the posterior semicircular canal. The diagnosis is confirmed by eliciting characteristic symptoms during the Dix-Hallpike test. Although the BPPV usually is a self-limited disorder treatment with a specific bedside maneuver is effective and can shorten the duration of symptoms.     

Diagnosis and therapeutic options in benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is one of the most common and treatable causes of vertigo. We examined BPPV types and the effectiveness of physical therapy in each type. BPPV is caused by a utricular statoconium that blocks the semicircular canal. Statoconia can block any of the semicircular canals, but they generally affects the posterior canal. Diagnosis is based on a typical history and characteristic eye movements elicited by the Dix-Hallpike test. Treatment involves a physical maneuver designed to mobilize the free calcium particles from the semicircular canal to the utricle. Canalith repositioning is the mainstay of treatment. The maneuver is illustrated in detail and other forms of treatment and their indications are discussed.     

Fenestration and occlusion of the posterior semicircular canal for benign positional vertigo

Benign positional vertigo is a potentially disabling condition characterized by episodic vertigo following certain provocative head movements. In most patients it is self limiting; however, in a few it may prove intractable, causing considerable social morbidity. In these patients surgery may be considered. Surgery previously involved section of the vestibular or singular nerves, involving a significant risk to hearing and to the facial nerve. Ablation of the labyrinth may even be considered. The new surgical technique of occlusion of the posterior semicircular canal has proved to be curative in most patients with benign positional vertigo with little risk to hearing. This paper describes our experience of fenestration and occlusion of the posterior semicircular canal in four patients.     

Fenestration and occlusion of the posterior semicircular canal for benign positional vertigo.

Benign positional vertigo is a potentially disabling condition characterized by episodic vertigo following certain provocative head movements. In most patients it is self limiting; however, in a few it may prove intractable, causing considerable social morbidity. In these patients surgery may be considered. Surgery previously involved section of the vestibular or singular nerves, involving a significant risk to hearing and to the facial nerve. Ablation of the labyrinth may even be considered. The new surgical technique of occlusion of the posterior semicircular canal has proved to be curative in most patients with benign positional vertigo with little risk of hearing. This paper describes our experience of fenestration and occlusion of the posterior semicircular canal in four patients.     

Partitioning of the labyrinth: application in benign paroxysmal positional vertigo.

Partitioning of the labyrinth is a new laser technique that creates a fibrous band within the inner ear. The application of this technique to benign paroxysmal positional vertigo (BPPV) is described in the first two patients to undergo this procedure. The partitioning technique involves blue-lining the posterior semicircular canal near its ampulla and lasing the blue-lined area. The technique provides a prompt decrease and the ultimate elimination of BPPV. There is some mild motion sensitivity of 6 to 8 weeks duration, and some transient (3-week) sensorineural hearing loss. The use of immediate postoperative low dose steroids provides marked decrease in the motion sensitivity and elimination of the transient sensorineural hearing loss. Lasing two adjacent areas on the posterior semicircular canal may prevent transient recurrence of the positional vertigo during the healing process.     

Three-dimensional reconstruction of the human semicircular canals and measurement of each membranous canal plane defined by Reid's stereotactic coordinates

OBJECTIVES: Equations for estimating the planar relationships of the human semicircular canals were devised by Blanks et al from a dissected bony labyrinth in a human skull. However, a similar study on the membranous semicircular canal planes has never been published. METHODS: In this study, the angle between each membranous canal plane and Reid's stereotactic horizontal plane was measured on serial histologic sections of 7 temporal bones from Japanese adults. We reconstructed the 3 semicircular canals by computer-aided 3-dimensional analysis. The angles between each pair of both bony and membranous canal planes were measured. RESULTS: In the bony labyrinth, the angles between the 2 canal planes of the lateral-anterior, anterior-posterior, and lateral-posterior pairs were 90.51 degrees +/- 2.98 degrees (mean +/- SD), 91.70 degrees +/- 1.85 degrees, and 94.52 degrees +/- 3.32 degrees, respectively. The angles between the 2 membranous canal planes of the lateral-anterior, anterior-posterior, and lateral-posterior pairs were 90.05 degrees +/- 4.74 degrees, 91.03 degrees +/- 2.93 degrees, and 91.92 degrees +/- 5.22 degrees, respectively. CONCLUSIONS: The data from our study of the membranous labyrinth showed that the angles between each canal plane and the others were much closer to 90 degrees than was found by Blanks et al for the bony labyrinth.     

Inkurabler und atypischer benigner paroxysmaler Lagerungsschwindel

Benign paroxysmal positional vertigo (BPPV) is the most frequent vestibular disorder and a most common cause of dizziness and vertigo. The modern canalolithiasis theory postulates the existence of free-floating dense otolithic particles in the endolymph of the posterior semicircular canal. The symptoms were exactly described by Dix and Hallpike; BPPV is normally a self-limited disease with spontaneous recovery. There is however a small number of patients who do not respond to any treatment or who present with otolithic vertigo which does not fit all Dix-Hallpike criteria (atypical BPPV). While BPPV in its typical appearance cannot be diagnosed with radiologic imaging, the authors succeeded in identifying structural changes in the vestibular organs of patients suffering from intractable or atypical BPPV using three-dimensional magnetic resonance imaging.     

Intractable and atypical benign paroxysmal vertigo. Pathological results of high-resolution three-dimensional MR-tomography of the vestibular organ

Benign paroxysmal positional vertigo (BPPV) is the most frequent vestibular disorder and a most common cause of dizziness and vertigo. The modern canalolithiasis theory postulates the existence of free-floating dense otolithic particles in the endolymph of the posterior semicircular canal. The symptoms were exactly described by Dix and Hallpike; BPPV is normally a self-limited disease with spontaneous recovery. There is however a small number of patients who do not respond to any treatment or who present with otolithic vertigo which does not fit all Dix-Hallpike criteria (atypical BPPV). While BPPV in its typical appearance cannot be diagnosed with radiologic imaging, the authors succeeded in identifying structural changes in the vestibular organs of patients suffering from intractable or atypical BPPV using three-dimensional magnetic resonance imaging.