RESPONSE TO LETTER TO THE EDITOR RE

Abstract

In Reply: We appreciate the thoughtful letter to the editor regarding our recent publication on our experience with anterior semicircular canal benign paroxysmal positional vertigo (BPPV). One of the major goals of our study was to increase awareness of the prevalence, demographics, and treatment success for BPPV involving the anterior canal (AC) and, therefore, stimulate further investigation into this condition. The question was raised on whether Figure 2 in our article represents the "best technique" for treating AC canalithiasis. We selected this method of treatment on the basis of the recommended canalith repositioning maneuvers for AC BPPV as described by Herdman (1), Brandt (2), and Korres and Balatsouras (3). All of these authors have suggested that maneuvers used to treat posterior canal (PC) involvement are also effective for AC involvement.FIG. 2: The modified Epley maneuver used to treat canalithiasis of the anterior semicircular canal when the left ear is affected. A, The patient is sitting with the head turned 45 degrees to the affected (left) ear. B, The patient is reclined into a head-hanging left position. C, The patient is rolled to the right. D, The patient is rolled further to the right onto side with face directed toward ground. E, The patient is brought into sitting position. For cupulolithiasis of the anterior semicircular canal, most cases respond to a true Epley, as shown below but with use of vibration. Reprinted from Otol Neurotol 2007;28:221.In our article, we referenced the article by Kim et al. (4) due to their large experience with BPPV patients with AC involvement, with specific attention to their treatment success. They had high success in treating their patients, as did we: they required an average of 1.97 maneuvers to treat their 30 patients, and in our study, we required an average of 1.32 maneuvers to treat our 55 patients. We indeed used the technique described in Figure 2 in our article to achieve the treatment success reported. Therefore, although different techniques were used by the two studies, it can be deduced that more than one repositioning maneuver can be effective in the treatment of AC BPPV. Anatomically, it makes sense that both techniques would work. If the vertical component of nystagmus induced by Dix-Hallpike maneuver has not been appreciated (which is quite possible without the use of video or electronystagmography), the maneuver used in our study would work for both AC or PC involvement; conversely, the maneuver used by Kim et al. (4) would only work for AC involvement and would be provoking if the PC is involved. Considering the reported success rates for treatment of AC BPPV, one can conclude that the clinician is given alternatives for treatment, which is especially useful if one technique is not successful. We thank you again for the question and welcome any further discussion. Lance Elliot Jackson, M.D., F.A.C.S. Barry Morgan, P.T. Ear Institute of Texas San Antonio, Texas, U.S.A.