Rhinological and Otological Society, Inc. Benign ...

The Laryngoscope
Lippincott Williams & Wilkins, Inc., Philadelphia
© 2001 The American Laryngological,
Rhinological and Otological Society, Inc.

Benign Paroxysmal Positional Vertigo After
Stapedectomy

Erbil Atacan, MD; Levent Sennaroglu, MD; Aydan Genc, PhD; Sefa Kaya, MD

Objective: To determine the incidence of benign cus and stapes footplate is essential in stapedectomy.
paroxysmal positional vertigo (BPPV) following sta- Key Words: Stapedectomy, complications, benign po-
pedectomy in a patient group and the efficacy of the sitional paroxysmal vertigo, canalolithiasis.
Epley maneuver in this group. Study Design: Prospec-
tive study in a university-based tertiary referral sys- Laryngoscope, 111:1257–1259, 2001
tem. Methods: The patient group comprised 63 pa-
tients who had undergone stapedectomy; a control INTRODUCTION
group consisted of normal healthy individuals with There have been major developments in the under-
no otolaryngological complaints. All individuals un-
derwent the Dix-Hallpike maneuver for the diagnosis standing of the pathophysiology and therapy of benign
of BPPV. Patients who exhibited vertigo, torsional paroxysmal positional vertigo (BPPV) during the last two
nystagmus (which reverses its direction on return to decades. In 1921, Barany described paroxysmal vertigo
sitting position) preceded by a latent period, and the with nystagmus following changes in head position.1
fatigability of these findings were considered to have Later, Dix and Hallpike2 introduced the term “benign
BPPV. If the test result was positive, they underwent positional paroxysmal vertigo” and described the Dix-
the Epley therapeutic maneuver. Results: Four of the Hallpike maneuver and criteria necessary for diagnosis of
patients who had undergone a stapedectomy showed BPPV.
characteristic findings of BPPV. No individual in the
control group had BPPV. All patients responded well Today, in the pathogenesis of BPPV, cerebellar, cer-
to the Epley maneuver. Conclusions: Stapedectomy vical, and vascular factors have lost their importance,1
may be regarded as an etiological factor in BPPV. and several other factors have been proposed. Schuknecht
Because the fenestra is located in the posterior part of and Ruby3 suggested the term “cupulolithiasis” when ba-
the stapes footplate, the pathophysiology appears to sophilic deposits were documented in the posterior semi-
be related to utricular rather than saccular trauma. circular canal. However, Hall et al.4 put forward the idea
Correct measurement of the distance between the in- that free-floating particles in the canal caused the disease,
cus and stapes footplate is essential in stapedectomy. and this mechanism came to be known as “canalolithia-
An Internet survey of the relevant literature in En- sis.” The latter term is most widely accepted today.
glish shows a scarcity of publications on the inci-
dence of BPPV following stapedectomy. In the Ear operations are considered to be among the etio-
present study, 63 patients who had undergone a sta- logical factors in BPPV; however, a survey of the relevant
pedectomy were investigated for the presence of literature in English through the Internet showed a scar-
BPPV; all had Dix-Hallpike maneuvers performed for city of publications on BPPV following stapedectomy.
the diagnosis. Sixty-three individuals with no otolar- Therefore, this study investigated a group of patients who
yngological complaints made up the control group. had undergone a stapedectomy, to determine the inci-
Four of the patients who had undergone stapedec- dence of BPPV after stapedectomy and the efficacy of the
tomy showed characteristic findings of BPPV, and no Epley maneuver in this patient group.
individual in the control group had BPPV; the differ-
ence between the two groups was statistically signif- MATERIALS AND METHODS
icant. All four of the patients diagnosed with BPPV
responded well to the Epley maneuver. The patho- The study was carried out in the Department of Otolaryn-
physiology appears to be related to utricular trauma. gology—Head and Neck Surgery at Hacettepe University
Correct measurement of the distance between the in- (Ankara, Turkey) on 63 patients who had had a stapedectomy.
There were 46 female and 17 male patients, with an age range of
From the Department of Otolaryngology—Head and Neck Surgery, 23 to 65 years (average age, 38.2 y). Preoperatively all patients
Hacettepe University Medical Faculty, Ankara, Turkey. had an air-bone gap of at least 30 dB (pure-tone average in
frequencies 500 Hz and 1 and 2 kHz), and clinical otosclerosis was
Editor’s Note: This Manuscript was accepted for publication March diagnosed.
8, 2001.
All patients with dizziness, vertigo, or inner ear involve-
Send Correspondence to Levent Sennaroglu, MD, 7/4 Serefli Sokak, ment were excluded from the study, but Dix-Hallpike maneuver
Mebusevleri 06490, Ankara, Turkey. was not performed routinely preoperatively. They had undergone
uneventful stapedectomy surgery. The surgical technique in-
Laryngoscope 111: July 2001
Atacan et al.: Vertigo After Stapedectomy

1257

volves removing the stapes superstructure and making a small none of these patients had exhibited BPPV symptoms
fenestra at the stapes footplate; the fenestra is created using a before the stapedectomy. All four patients had unilateral
sharp needle. A Teflon piston (either 0.6 or 0.8 mm in diameter BPPV on the side of the operation, and the characteristics
and 3.75– 4.5 mm in length as determined at the time of surgery) of the nystagmus were typical for posterior semicircular
is then used between the incus and the fenestra, and the opening canal BPPV in all cases. No subject in the control group
around the prosthesis is closed with crushed bony pieces from the exhibited symptoms or findings of BPPV, as revealed by
stapes superstructure. the Dix-Hallpike maneuver. The difference between the
two groups was statistically significant (P Ͻ.05).
Sixty-three adults with no otolaryngological or vestibular
complaints made up the control group. In this group, there were All 63 patients had had a small fenestra stapedec-
40 female and 23 male subjects with an age range of 20 to 63 tomy in the posterior part of the footplate. Their file
years (average age, 41 y). records indicated that the average length of the piston in
this group without vertigo and BPPV was 4.19 mm. The
The study group patients were evaluated for vertigo after lengths of the pistons used in the four patients who exhib-
surgery; a questionnaire about the presence and characteristics of ited symptoms of BPPV were recorded in their files as 4.5,
vertigo was completed by each of the patients. Because most 4.5, 4.25, and 4.25 mm, respectively.
patients demonstrate some vertigo and nystagmus during the
first month after surgery, the evaluation for vertigo was not The four patients with BPPV underwent the Epley
performed within this period. The evaluation period was 8 to 348 maneuver for therapy. Their progress was followed weekly
months after surgery. After an ENT examination, patients un- for a period of 1 month. None of them complained of
derwent a complete audiological evaluation. Patients with the vertigo, and none demonstrated vertigo or nystagmus dur-
findings of Meniere’s disease were excluded from the study. The ing follow-up Dix-Hallpike testing.
Dix-Hallpike maneuver5 was used for all patients and control
subjects to diagnose BPPV. Patients who exhibited vertigo, tor- DISCUSSION
sional nystagmus (which reverses its direction on return to sit- This study revealed a 6.3% incidence of BPPV follow-
ting position) preceded by a latent period, and fatigability of these
findings were considered to have BPPV. ing stapedectomy. In the control group of healthy individ-
uals, no case of BPPV could be demonstrated. The differ-
The operative notes for all of the patients were reviewed; the ence between the two groups was statistically significant
size and position of the fenestra at the footplate and the diameter (P Ͻ.05). All four patients with BPPV showed no further
and length of the piston were noted. symptoms during 1 month of follow-up after the Epley
maneuver.
Patients with BPPV were given the Epley maneuver5 for ther-
apy, and their progress was followed every week for 1 month. In According to Baloh et al.,6 no cause could be identi-
their control examination the Dix-Hallpike maneuver was repeated fied in 48% of their case studies of patients with BPPV.
to determine whether vertigo and nystagmus still persisted. The etiological factors include head injury, vestibular neu-
ritis, otological infections, and prolonged bed rest. Ear
The difference between the patient and the control groups surgery is another etiological factor in BPPV. Hughes and
was tested statistically using the “difference-between-the-two- Proctor1 noted that in 151 cases of BPPV, 6 followed ear
proportions test.” surgery. Five of the operations they described were stape-
dectomies and one was a tympanoplasty, but no explana-
RESULTS tion was provided by these authors to account for BPPV
Four patients (6.3%) in the group who had had sta- after stapedectomy or tympanoplasty in these cases.

pedectomy exhibited characteristic findings of BPPV; Today, the pathophysiology of BPPV is generally un-
derstood to be a result of canalolithiasis in which otoconia
Fig. 1. Proximity of membranous labyrinth to stapes footplate (SF) dislodged from the maculae of the otolith organs accumu-
with Teflon piston (TF) in the posterior part. S ϭ saccule; U ϭ utricle. late in the long arm of the posterior semicircular canal.
Cupulolithiasis, as originally proposed by Schucknecht
Laryngoscope 111: July 2001 and Ruby,3 cannot explain the paroxysmal nature of the
1258 disease, the brief duration of the nystagmus, the reversal
of the nystagmus, or the fatigability of these findings.
Further evidence of the causative role of canalolithiasis in
BPPV came from Parnes and McClure,7 when they ob-
served particulate material within the long arm of the
posterior semicircular canal during semicircular canal oc-
clusion operations.

The pathophysiology of BPPV after stapedectomy
may be related to trauma to the otolith organs. The stapes
footplate lies lateral to the utricle and saccule (Fig. 1). The
distance between the footplate and the labyrinthine ele-
ments is of the magnitude of a millimeter. According to
Donaldson et al.,8 the distance from the superior surface
of the footplate to the saccule, which lies anterior and
medial to the footplate, varies between 1.0 and 1.4 mm
(the shortest distance is 0.82 mm). The corresponding

Atacan et al.: Vertigo After Stapedectomy

distance for the utricle, which lies posterior and medial to Collison and Kolberg13 reported a case of persistent BPPV
the footplate, varies between 0.7 and 1.4 mm (the shortest after stapedectomy and its successful treatment with the
distance is 0.38 mm). Therefore, anatomically there is a Epley maneuver. Their case report indicated that the
close relationship between the footplate and membranous pathophysiology was most probably related to a floating
structures in the vestibule. Ideally, the tip of the piston footplate, which tilted on its short axis and came into
should be 0.25 mm below the stapes footplate. If the utri- contact with the membranous labyrinth at the utricle.
cle is close to the footplate and the tip of the piston extends This caused dislodgment of the otoconia into the semicir-
further than 0.25 mm within the vestibule, utricular cular canals. Morgestern and Greven14 had to perform
trauma is likely. This in turn may mobilize the otoliths surgery to treat BPPV after a stapedectomy, but at the
into the long arm of the posterior semicircular canal, time of their study the Epley maneuver was not yet
which is the most dependent part of the membranous known. All of our four patients responded well to the
labyrinth. We think this may be the underlying patho- Epley maneuver.
physiology of BPPV after stapedectomy.
CONCLUSION
Causse et al.9 indicated that the posterior part of the Stapedectomy may be considered among the etiolog-
footplate is the only location where the piston shaft is not
directly above the membranous labyrinth. As a result of ical factors in BPPV, and the physiopathological mecha-
this, the fenestra during stapedectomy is usually located nism appears to be utricular trauma. It should be kept in
in the posterior part of the footplate. The fenestra was mind that in 2% of the patients the membranous labyrinth
located in the posterior part of the footplate in all of our is close to the footplate. This indicates the importance of
patients; this leads us away from the conclusion that there correctly measuring the distance between the long process
was trauma to the saccule, which is located anterior and of the incus and the footplate; the tip of the prosthesis
medial to the footplate. Meyerhof10 suggested that utric- should be just within the vestibule. Patients exhibiting
ular trauma may be the origin and that otoliths mobilized BPPV after stapedectomy responded well to the Epley
in this way may enter the semicircular canal; this view maneuver.
correlates with our findings.
BIBLIOGRAPHY
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