What is the treatment for symptoms caused by inner ear crystals, specifically benign paroxysmal positional vertigo (BPPV)?

Treatment for Benign Paroxysmal Positional Vertigo (BPPV)

Canalith repositioning procedures (CRPs) are the first-line treatment for BPPV, with success rates of 80-90% after 1-3 treatments. 1, 2

Diagnosis of BPPV

BPPV is diagnosed through:

• Dix-Hallpike test: Gold standard for posterior canal BPPV 2
• Supine roll test: For lateral (horizontal) canal BPPV 2

These tests involve specific head movements that trigger characteristic nystagmus (eye movements) when crystals are displaced in the semicircular canals.

Treatment Algorithm

First-Line Treatment: Canalith Repositioning Procedures

1. For posterior canal BPPV (most common type):

   • Epley maneuver
   • Semont (liberatory) maneuver

2. For horizontal canal BPPV:

   • Barbecue roll maneuver
   • Gufoni maneuver

3. For anterior canal BPPV (rare):

   • Modified Epley maneuver

The choice between maneuvers depends on:

• Canal involved
• Patient's physical limitations
• Clinician's experience
• Previous treatment failures

Treatment Effectiveness

• Success rate: 80-90% with 1-3 treatments 1, 2, 3
• Average number of sessions needed: Three 4
• Recurrence rate: Approximately 16-36% at 6 months 1, 4

Special Considerations

• Elderly patients: May benefit more from vestibular rehabilitation in addition to CRPs 2
• Patients with mobility issues: May require assistance or modified techniques 2
• Self-repositioning: Patients can be taught to perform these maneuvers at home under supervision 1

Medication Use

Medications are not recommended as primary treatment for BPPV 1. They may be used only for:

• Short-term symptom relief of nausea during acute episodes
• Temporary management of severe distress

If medications are needed temporarily:

• Meclizine: 25-100 mg daily in divided doses 5
• Caution: May cause drowsiness; patients should avoid driving and alcohol 5
• Contraindications: Use with caution in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects 5

Post-Treatment Management

• Follow-up: Reassess within 1 month after treatment to confirm symptom resolution 2
• Precautions: Patients should be advised about increased fall risk, especially in the elderly 1, 2
• Patient education: Inform about possible recurrence and recognition signs 2

Common Pitfalls to Avoid

1. Overuse of medications: Vestibular suppressants like meclizine are not recommended as primary treatment and may delay central compensation 6
2. Unnecessary imaging: CT or MRI is not needed to diagnose BPPV 1, 6
3. Inadequate follow-up: Failure to reassess may miss persistent BPPV or alternative diagnoses 2
4. Overlooking multiple canal involvement: Some patients may have crystals in more than one canal 3

When to Consider Alternative Diagnoses

Consider alternative diagnoses if:

• Symptoms persist despite multiple properly performed repositioning maneuvers
• Atypical symptoms are present (hearing loss, neurological symptoms)
• Nystagmus pattern is inconsistent with BPPV

In these cases, referral to a specialist (otolaryngologist or neurologist) may be warranted to rule out other vestibular or central nervous system disorders 1.