BPPV 3

THE NEW ZEALAND
MEDICAL JOURNAL
Journal of the New Zealand Medical Association
Superior canal benign positional vertigo

Jeremy Hornibrook
The most common cause of vertigo is benign positional vertigo (BPV). Positionallyinduced vertigo was recognised early in the 20th Century, but the clinical features of
classical BPV were not described until 1952 by Dix and Hallpike,1 based on their
provocative positional test. The patient is seated near the end of the examination
couch, preferably wearing Fenzel glasses to magnify the eyes for the examiner.
The head is turned 45 degrees to one side and the patient tipped back with the head
down. After a few seconds the patient experiences vertigo and has torsional geotropic
(fast phase towards the ground) nystagmus seen when the eyes are directed towards
the symptomatic side. The nystagmus and vertigo usually last less than 30 seconds.
When the patient is sat up, the nystagmus direction reverses.
Dix and Hallpike suspected the disorder was caused by an abnormality of the otolith
organs. With the advantage of high quality temporal bone histology Schuknecht2
thought that the nystagmus was explained by a posterior canal receptor made heavy,
most likely by an otoconial particle which had become attached to it.
Early attempts at treatment were based on that assumption. Others, including Epley,
made models and concluded that the classical signs were better explained by a
particle loose in the posterior canal. A photograph of otoconia in a surgically opened
posterior canal and the eventual acceptance that repositioning treatments work have
confirmed the mechanism.3
In the early days of vestibular research (before video cameras) torsional nystagmus
was difficult to record. Electronystagmographic recordings favoured nystagmus in the
horizontal plane. However, it was by this technique that the first recordings of
horizontal canal BPV were made.4 These confirmed Epleys prediction that BPV
could be caused by otoconia in any semicircular canal.5 Epley presented a chart
showing the likely pattern of nystagmus for each type.
In the 1960s, experiments in cats had defined the unique three-neuron connection
between canal receptors and the extraocular muscles.6 Each receptor is connected to
one ipsilateral and one contralateral muscle. The second-order neurons are either
excitatory (to the agonist muscles) or inhibitory (to the antagonist muscles). The
connections for a posterior canal receptor and a superior canal receptor in a left ear
are shown in Figure 1 and Figure 2.
In classical posterior canal BPV, a provocative positional test will cause an
ampullo-fugal (excitatory) deflection of the posterior canal receptor resulting in a
torsional apogeotropic (anatomically downward) deflection of the eyes, followed by
their fast-phase return (geotropic or anatomically upward). If there were a particle in a
superior canal, a similar ampullofugal receptor deflection could occur during a
provocative positional test when the symptomatic ear is upper-most (Figure 2).
NZMJ 19 September 2008, Vol 121 No 1282; ISSN 1175 8716

URL: http://www.nzma.org.nz/journal/121-1282/3270/
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Figure 1. Left posterior canal benign positional vertigo. Left ear down
(IR=inferior rectus, SO=superior oblique, SR=superior rectus, IO=inferior oblique)
Figure 2. Left superior canal benign positional vertigo. Left ear up

(IO=inferior oblique, SR=superior rectus, SO=superior oblique, IR=inferior rectus)

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Case report
A 51-year-old female had an approximately 10-year history of episodic positional
vertigo lasting days which would occur twice a year. In 2000 it was confirmed as
being classical left posterior canal BPV. In 2004 she presented after having awoken
with postional vertigo. When sitting she had no nystagmus.
A Hallpike provocative positional test was performed (Figure 3). With the left ear
down there was no response. With the right ear down, after 5 seconds, she
experienced vertigo and there was a nystagmus whose fast phase was apogeotropic
(anatomically downward), which ceased when she sat up. This implied BPV
generated by a superior canal receptor, most likely in the opposite (left, upper) ear.
On that presumption two reverse (beginning with left ear up) Epley canalith
repositioning procedure sequences7 were performed, after which no positional
nystagmus could be elicited. She remained free of symptoms until approximately 6
months later when she presented with horizontal canal BPV in the same ear. This
patient has now had all three types of BPV in one ear.
Figure 3. Video-clip. Hallpike positional test with right ear down and left ear up.
Downbeat nystagmus with a latency of 5 seconds and a small torsional
component
Video can be viewed at http://www.nzma.org.nz/journal/121-1282/3270/video.mpeg
(8MB)
Discussion
Vertical nystagmus, particularly downbeat, should alert the clinician to the possibility
of central pathology. Caudal brainstem compression (e.g. Chiari malformation,
hereditary spinocerebellar ataxia, and long-term lithium therapy) is in approximately
half of the main causes. In the other half no cause is found.8
Until relatively recently it was assumed that positionally-induced nystagmus that was
not "classical" BPV must have a central cause. The discovery of horizontal canal BPV
explained most of the variations. In 1995, Epleys elegant description of superior
canal BPV was theoretical.
In 1994, Brandt9 had alluded to the rare anterior [superior] canal BPPV, the
spontaneous symptoms occur when the affected ear is uppermost. However, the first
detailed cases are attributed to Susan Herdman10 who described two patients whose
positionally-induced vertigo was accompanied by downbeat and torsional nystagmus
likely to be caused by a superior canal receptor, and which ceased after repositioning
treatment appropriate for BPV. Subsequently superior canal BPV has been recognised
and reported by others1015 in whose series it represents approximately 1% of all BPV
diagnoses.

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Bertholon et al13 reviewed 50 consecutive patients who had positionally-induced

Nystagmus. In 75% there was a central cause (multiple system atrophy, cerebellar
degeneration and other miscellaneous causes). In nearly all the downbeat nystagmus
was triggered by the Hallpike test, and its onset was immediate.
In 25% (idiopathic) who presented with positional vertigo, the Hallpike test or a
head-hanging test elicited vertigo and downbeat nystagmus with a short latency. In
half the subjects a torsional component could be seen through Frenzel glasses, but in
one it was only discernible by video-imaging. Aw et al15 studied forty-four
consecutive patients who had not responded to conventional office repositioning
treatments with 3-dimensional search coils in a 2-axis whole-body rotator. Seven had
downbeat nystagmus with a torsional component assumed to indicate the symptomatic
superior canal. All responded to a head-over-heels forward rotation in the plane of
the identified canal.
Superior canal BPV is assumed to be rare because the posterior arm of the canal
descends directly to the common crus, and debris within it should clear easily. For
that reason, like horizontal canal BPV, it often resolves quickly with changes in head
orientation likely to occur in everyday activities, or turning over in bed.
Differences in the orientation of the ampullary segments of the posterior and superior
canals explain why (1) superior canal BPV can be elicited by a Hallpike test to either
side, or to a head-hanging test, and (2) the smaller torsional component for superior
canal BPV, which is predominantly downbeat.13,15
In summary, superior canal BPV is now recognised as rare form of BPV, observed in
approximately 1% of large series. The presenting symptom is positional vertigo. As
with all forms of BPV the patient must experience vertigo on a Hallpike positional
test, which may be positive to either side, or on a head-hanging test.
The nystagmus has a short latency and is downbeat, with a torsional component which
may be indiscernible to clinical observation. A past history of posterior or horizontal
canal BPV supports the likelihood of superior canal BPV. Otherwise, in a patient with
positionally-induced downbeat nystagmus, the absence of these features and nonresponse to respositioning treatment makes a central cause likely.
Author information: Jeremy Hornibrook, OtolaryngologistHead & Neck Surgeon,
Christchurch Hospital (and Adjunct Professor in the Department of Communication
Disorders, University of Canterbury), Christchurch
Acknowledgment: I thank Professor GM Halmagyii (at the Royal Prince Alfred
Hospital, Sydney) for verification of the observations and conclusions and for helpful
comments.
Correspondence: Jeremy Hornibrook, Department of Otolaryngology-HNS,
Christchurch Hospital, Private Bag 4710 Christchurch, New Zealand. Fax: +64 (0)3
364 0273; email [email protected]
References:
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Dix R, Hallpike CS. The pathology, symptomatology and diagnosis of certain common
disorders of the vestibular system. Proc Roy Soc Med. 1952;45:34154.
Schuknecht HF. Cupulolithiasis. Arch Otolaryngol Head Neck Surg. 1969;90:13326.
Hornibrook J. Treatment for positional vertigo. N Z Med J. 1998;111:3312.

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McClure, JA. Horizontal canal BPV. J Otolaryngol. 1985;14:305.

Epley JM. Positional vertigo related to semicircular canalithiasis. Otolaryngol Head Neck
Surg. 1995;112:15461.
Cohen B, Suzuki JI, Bender MB. Eye movements from semicircular canal stimulation in the
cat. Ann Otol Rhinol Laryngol. 1964;73:15369.
Epley JM. The canalith repositioning procedure: for treatment of benign positional vertigo.
Otolaryngol Head Neck Surg. 1992;107;339404.
Halmagyii GM, Leigh RJ. Upbeat about downbeat nystagmus. Neurology. 2004;63:6067.
Brandt T, Steddin S, Daroff RB. Therapy for benign paroxysmal positioning vertigo, revisited.
Neurology. 1994;44;796800.
Herdman SJ, Tusa RJ. Complications of the canalith repositioning procedure. Arch
Otolaryngol Head Neck Surg. 1996;122:2816.
Honrubia V, Baloh RW, Harris MR, et al. Paroxysmal positional vertigo syndrome. Am J
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Brantberg K, Bergenius J. Treatment of anterior benign positional vertigo by canal plugging: a
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Bertholon, P, Bronstein AM, Davies RA et al. Positional downbeating nystagmus in 50
patients: cerebellar disorders and possible anterior semicircular canalithiasis. J Neurol
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Korres S, Balatsouras DG, Kaberos A, et al. Occurrence of semicircular canal involvement in
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Aw ST, Todd MJ, Aw GE, et al. Benign positional nystagmus: A study of its threedimensional spatio-temporal characteristics. Neurology. 2005;64:1897905.
Schratzenstaller B, Wagner-Manlsau C, Strasser G, et al. Canalithiasis of the superior
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THE NEW ZEALAND

Superior canal benign positional vertigo

NZMJ 19 September 2008, Vol 121 No 1282; ISSN 1175 8716

Figure 2. Left superior canal benign positional vertigo. Left ear up

NZMJ 19 September 2008, Vol 121 No 1282; ISSN 1175 8716

NZMJ 19 September 2008, Vol 121 No 1282; ISSN 1175 8716

Bertholon et al13 reviewed 50 consecutive patients who had positionally-induced

NZMJ 19 September 2008, Vol 121 No 1282; ISSN 1175 8716

McClure, JA. Horizontal canal BPV. J Otolaryngol. 1985;14:305.

NZMJ 19 September 2008, Vol 121 No 1282; ISSN 1175 8716

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