When the brain senses difficulty in keeping the eyes fixed on an object while moving rapidly, it increases the signal from the inner ear to adjust. By improving the communication between these systems, specific exercises aim to enhance visual stability. The inner ear and vestibular system play a crucial role in maintaining stable and focused vision while moving the head. It generally goes away in a week or two with normal activity, but recovery may be accelerated by performing VOR exercises. Residual non-vertigo dizziness is a common complaint after successful canalith repositioning for BPPV. After successful maneuvers, the brain adapted to the new condition is unable to quickly readjust to the old pattern and this could be the cause of RD” The Bottom Line This new equilibrium tends to stabilize the perturbation produced by the otoconia that is free to float in the semicircular canals.
![epley epley](https://www.cmaj.ca/content/cmaj/169/7/681/F8.large.jpg)
point of view, the genesis of residual dizziness (RD) could reside in the inability of the vestibular system to readapt quickly to a new functional state: in detail the persistence of debris in the semicircular canal could alter the tonic discharge from the affected labyrinth and could induce a new central adaptation rebalancing the vestibular nuclei activity, in order to minimize the peripheral asymmetry. This theory has been explored by Faralli et al: It is plausible that it takes some time for the brain to readjust to a newly healthy labyrinth. With canalith repositioning, there is not a gradual recovery, but rather an immediate repair. It is also possible, but currently unproven, that the brain’s response to intermittent bursts of increased unilateral discharge (which occurs with BPPV) is to dampen it’s connection to the affected ear, or maybe just the affected canal. We know that the brain has the ability to reduce the gain of the vestibular ocular reflex (VOR) in the healthy ear following an acute unilateral vestibular loss. I can’t add much to that discussion, but a review of available literature can be found here.Ī second theory is that there is a neural dampening or “cerebellar clamp” process. A damaged utricle is the source of BPPV (that is where the otoconia debris comes from). One theory involves utricular dysfunction. There are two schools of thought regarding these residual symptoms.
![epley epley](https://i.pinimg.com/736x/74/0e/cd/740ecd75f767f805975a0ce203c21008--epley-maneuver-vestibular.jpg)
Residual Non-Vertigo Dizziness Following the Epley ManueverĪ high percentage of patients will report resolution of positional vertigo after undergoing a repositioning treatment, but more than one in three will continue to describe more vague symptoms of imbalance and movement related visual disorientation and instability in the days to weeks following treatment. There is a recommended treatment for this, known as the Gufoni maneuver, but it does not enjoy nearly the same success rate as the Epley maneuver for posterior canal BPPV. This form of BPPV is characterized by ageotropic horizontal nystagmus where the nystagmus beat to the left after rolling onto the right side, and then change to right beating horizontal nystagmus after rolling onto the left side. One particular form of horizontal canal BPPV, where the otoconia is believed to be in the long arm of the canal, close to the ampulla, is particularly resistant to repositioning.
![epley epley](https://i.pinimg.com/236x/5a/19/44/5a1944e740fa0d4d2f250aa3d07575f0.jpg)
There are procedures for horizontal canal BPPV, but with lower success rates. The Epley maneuver is specifically for posterior canal BPPV and would not help BPPV of the horizontal canal. There are other forms of BPPV where the otoconia enter the horizontal canal, and very rarely the anterior canal. Numerous studies put the success rate for BPPV of the posterior canal in the high 90% range. In fact, success rate is so high that if the treatment fails, it is more likely that the diagnosis is wrong than it is that the repositioning procedure failed to move otoconia out of the posterior canal. First, no treatment works on everybody, but repositioning for BPPV has a very high success rate. Some patients continue to complain of positional vertigo after undergoing treatment with the Epley maneuver. Residual Dizziness: Repositioning Failure? So let’s revisit that and explore some related newer reports, as well as talk about people that do not improve after repositioning for BPPV type of vertigo. A few years ago, I did a post here discussing patients that continued to complain of imbalance and “fleeting disorientation” after successful treatment using the Epley maneuver or some other form of canalith repositioning.