Sei sulla pagina 1di 6

ACTA OTORHINOLARYNGOL ITAL 2003;23:10-15

“Step by step” treatment of lateral semicircular canal


canalolithiasis under videonystagmoscopic
examination
Riabilitazione “step by step” della canalolitiasi del canale semicircolare
laterale sotto controllo videonistagmoscopico
G. ASPRELLA LIBONATI, G. GAGLIARDI, D. CIFARELLI, G. LAROTONDA
Department of Otorhinolaryngology and Head-Neck Surgery, Hospital of Matera, Italy

Key words Parole chiave

Vertigo • Benign paroxysmal positional vertigo • Vertigine • Vertigine parossistica posizionale benigna •
Canalolithiasis • Lateral semicircular canal • Therapy • Canalolitiasi • Canale semicircolare laterale • Terapia•
Liberatory manoeuvres Manovre liberatorie

Summary Riassunto
Aim of the work was to describe a new physical thera- Lo scopo del lavoro è quello di esporre una nuova metodologia
peutic approach for benign paroxysmal positional vertigo di approccio riabilitativo per la vertigine parossistica posizio-
determined by canalolithiasis of the lateral semicircular nale benigna da canalolitiasi del Canale Semicircolare Latera-
canal. A review is made of the literature, and personal expe- le. Dopo una revisione della letteratura, viene riportata l’espe-
rience is reported. A total of 55 cases were observed, 40 rienza degli Autori. Sono stati osservati 55 casi, di cui 40 forme
geotropic forms, 15 apogeotropic forms. Liberatory geotrope e 15 apogeotrope. Le manovre riabilitative sono state
manoeuvres were carried out observing the nystagmus eseguite osservando sempre il nistagmo sotto videonistagmo-
during videonystagmoscopic examination, thus attempting scopia, cercando così di raggiungere la risoluzione già nel cor-
to solve the problem in the first treatment session. Moni- so della prima seduta terapeutica: infatti monitorizzando il pa-
toring the patient under videonystagmoscopic examination, ziente in videonistagmoscopia, il progredire in senso ampullifu-
progression of the otolithic mass towards the non-ampullary go dell’ammasso otolitico è testimoniato dalla comparsa di un
segment is documented by the appearance of a nystagmus nistagmo diretto verso il lato sano (quindi inibitorio, da defles-
directed towards the healthy side (and, therefore, inhibitory, sione ampullifuga della cupola ampollare) durante l’esecuzio-
due to ampullofugal deflection of the ampullary cupula) ne dei singoli step del trattamento riabilitativo. Delle 40 forme
during the individual steps of the rehabilitation treatment. inizialmente geotrope, 30 hanno risolto con tecnica di Vannuc-
Of the 40 geotropic forms, 30 were successfully treated chi-Asprella, altre 10 con manovra di Vannucchi-Asprella pro-
with the Vannucchi-Asprella technique, and the other 10 seguita con barbecue rotation sec. Lempert. Delle 15 forme
with the Vannucchi-Asprella manoeuvre followed by a apogeotrope, 6 hanno risolto con la manovra di Vannucchi-
Lempert barbecue rotation. Of the 15 apogeotropic forms, Asprella, 2 hanno risolto con tecnica di Vannucchi-Asprella
6 were solved with the Vannucchi-Asprella manoeuvre, 2 proseguita con Lempert, 6 sono giunte a guarigione con tecni-
with the Vannucchi-Asprella technique followed by ca di Gufoni invertita, proseguita con Lempert, 1 ha trasforma-
Lempert, 6 with the inverted Gufoni technique, followed to in geotropo dopo Gufoni invertita più Lempert ed ha quindi
by Lempert, 1 transformed into geotropic with inverted risolto con successiva manovra di Vannucchi-Asprella. In tutti i
Gufoni plus Lempert and then resolved by means of a pazienti è stato conseguito il successo terapeutico nel corso
Vannucchi-Asprella manoeuvre. In all cases, therapeutic della prima seduta. La riabilitazione della vertigine parossisti-
success was achieved in the first session. Treatment of ca posizionale benigna da canalolitiasi del canale semicircola-
benign paroxysmal positional vertigo of the lateral semi- re laterale, come deducibile dalla revisione della letteratura,
circular canal does not allow every case to be fully solved non consente una piena risoluzione di tutti i casi alla loro pri-
at the first attempt with any technique proposed up to now, ma osservazione con nessuna delle tecniche sino ad ora propo-
in particular, for the apogeotropic forms. Being aware of ste dai vari Autori, ed in particolare per le forme apogeotrope.
the different techniques, choosing that most appropriate for Possedere buona dimestichezza con diverse tecniche, scegliere
the patient’s “physical” needs, and, above all, verifying la più adatta alle esigenze “fisiche” del paziente e, soprattutto,
under videonystagmoscopic examination the progression in verificare in videonistagmoscopia la progressione in senso am-
an ampullofugal direction of the otolithic mass during treat- pullifugo dell’ammasso otolitico durante la riabilitazione, con-
ment enable excellent therapeutic results to be obtained in sente di ottimizzare il risultato terapeutico nel trattamento del-
the treatment of benign paroxysmal positional vertigo of la vertigine parossistica posizionale benigna del canale semi-
the lateral semicircular canal, by modifying the rehabilita- circolare laterale, modificando la strategia riabilitativa in cor-
tion strategy while it is being carried out. Videonystagmo- so di esecuzione. Il controllo del nistagmo in videonistagmo-
scopic examination monitoring of the nystagmus during scopia durante la riabilitazione delle vertigine parossistica po-
treatment of benign paroxysmal positional vertigo of the sizionale benigna da canalolitiasi del canale semicircolare la-

10
TREATMENT OF LATERAL SEMICIRCULAR CANAL CANALOLITHIASIS

lateral semicircular canal, is taking the place of the rigid terale, superando il rigido schematismo delle manovre proposte
schematism of the manoeuvres proposed, so far, allowing sino ad oggi in letteratura, consente di adattare “step by step”
the treatment programme to be adapted to the individual il programma riabilitativo al singolo caso, così da permettere,
case, thus enabling a solution to be reached in the first attraverso una terapia individualizzata, il raggiungimento del-
rehabilitation session by means of tailored therapy. la risoluzione già dalla prima seduta riabilitativa.

Introduction mass moves in its gravitational sedimentation in the


lateral position, according to the canal segment it is
Benign paroxysmal positional vertigo (BPPV) due to in. Lying on the impaired side causes detritus in the
canalolithiasis of the lateral semicircular canal (LSC) ampullary segment to move away from the cupula, re-
is a nosologic entity that has been known for over 15 sulting in an inhibitory ampullofugal endolymphatic
years, the first mention in the literature being made in current, leading to apogeotropic PPNy, directed to-
1985 1; the Authors describe the typical clinical pic- wards the unstimulated ear. Turning the head to the
ture of a BPPV of the LSC, characterised by a bidi- opposite side causes the particles to fall towards the
rectional horizontal geotropic nystagmus, biposition- ampulla, with an excitatory discharge, and a PPNy di-
al in the lateral right and left positions. rected towards the pathological side, therefore, once
In 1989, Pagnini et al. 2 reported 15 cases of BPPV of again, apogeotropic. The transformation of the Ny
the LSC, classifying it as a true, autonomous noso- from apogeotropic to geotropic is explained by the
logic entity. These Authors described the evolution, migration of the otoconial mass in the posterior seg-
the symptomatological and semeiological features, ment of the LSC, with a consequent inversion of di-
advancing a hypothesis regarding the pathogenetic rection, with respect to the cupula, in the movement
mechanism of the typical paroxysmal positional nys- of the detritus, induced by gravitational pull with the
tagmus (PPNy). This mechanism is explained with lateral rotations of the head. The PPNy of greatest in-
the endolymphatic currents induced by movement in tensity in the apogeotropic variant is observed in the
the posterior segment of the LSC of detritus proba- supine position on the uninvolved side, and this is in
bly of otoconial origin. In rotating the pathological keeping with the second law of Ewald, in that excita-
side, the particles sediment towards the ampulla on tory stimulation from an ampullopetal endolymphatic
account of gravity, generating an utriculopetal, and, current occurs when the diseased ear is uppermost.
therefore, an excitatory, endolymphatic current, and In 1996, Nuti et al. 5 reported findings in a study on
the consequent nystagmus (Ny) towards the involved 123 patients suffering from BPPV of the LSC, from
ear, therefore, geotropic. On rolling over to the op- which they extrapolated 5 typical cases to illustrate
posite side, the particles move towards the non-am- possible clinical variants of the syndrome, examining
pullary segment, with an utriculofugal, and, there- the semeiotic aspects of the nystagmi observed and
fore, inhibitory, endolymphatic current. The Ny gen- proposing a physiopathological explanation for these
erated will, therefore, again be geotropic, directed in view of the canalolithiasis theory.
towards the lower ear, that is, towards the healthy
side. The Authors stress a greater intensity of Ny on
the impaired side, explained by the second law of Patients and Methods
Ewald 3, which postulates that the response to an ex-
citatory stimulus is always more intense than that fol- Cases related to 2001 are herewith reported: 55 of
lowing an inhibitory stimulus. This was also the first BPPV due to canalolithiasis of the LSC were treated,
report of forms originating as apogeotropic PPNy and 40 geotropic and 15 apogeotropic forms.
then transforming spontaneously into geotropic. The rehabilitation techniques used were, in the geo-
In 1994, Pagnini et al. 4 reported ten other cases of tropic forms (Fig. 1), the Vannucchi-Asprella ma-
BPPV of the LSC with purely bidirectional horizontal noeuvre (Fig. 2) and the Lempert (Fig. 3); in the apo-
PPNy, originating as apogeotropic; they describe the geotropic forms (Fig. 4). The Gufoni technique (Fig.
semeiotic and physiopathological features, thus iden- 5) was also used in several cases.
tifying a variant of BPPV of the LSC. An inversion of The therapeutic approach was tailored to suit the
the PPNy in geotropic takes place in all the patients, needs of the individual patient’s physical condition:
in the course of the first or a later session. The Au- arthrosis, obesity, recent injuries, plaster casts, multi-
thors suggest that this behaviour of the Ny may be re- ple neurovegetative disorders.
lated to a different collocation of the otoconial mass The rehabilitation manoeuvres were always carried
inside the LSC. In fact, if one considers division of out while monitoring the nystagmus under videonys-
the LSC into two halves, the simple or posterior seg- tagmoscopic control, in order to monitor the progres-
ment and the ampullary or anterior segment, it is not sion of the otolithic mass away from the ampulla,
difficult to imagine the different ways the otolithic which was confirmed by the appearance of a nystag-

11
G. ASPRELLA LIBONATI ET AL.

ting to a supine position, and immediately after the


sudden latero-rotation of the head towards the
healthy side, with the patient lying supine. This find-
ing was interpreted as indicative of a likely resolu-
tion of the problem. In 16 cases, this occurred after
the first 3-4 manoeuvres (although, as a precaution-
ary measure, a minimum of 5 manoeuvres were al-
ways carried out); in 6 other cases, this occurred af-
ter 5-6 manoeuvres, while 8-10 manoeuvres were re-
quired in the remaining 8 patients (Table I).
In 10 cases (Table I), after the disappearance of the
horizontal nystagmus towards the healthy side, oc-
Fig. 1. Geotropic forms: liberatory manoeuvres carried curring, on average, after 3-4 manoeuvres, a horizon-
out.
tal nystagmus appeared, directed towards the patho-
logical side, when returning to a supine, from a seat-
ed, position. This finding was interpreted as indica-
tive of an ampullopetal reflux of the otoconial mass,
brought closer by the rotatory steps to the utricular
orifice, without, however, passing through it. It was,
therefore, decided to continue with a further 90° lat-
eral rotation of the head with the patient supine on
the healthy side, with a Lempert barbecue rotation
technique (Fig. 3). The reappearance of a horizontal
nystagmus directed towards the healthy side while
this technique was being carried out, was taken as in-
dicative of a ampullofugal progression of the
otoliths. Verification with a diagnostic manoeuvre, at
the end of the session confirmed that the problem had
been solved.
In the apogeotropic forms (Fig. 4), transformation in-
to a geotropic form was attempted in 8 cases with the
Vannucchi-Asprella manoeuvre towards the healthy
side. In 6 of these cases, a nystagmus directed to-
wards the healthy side (and, therefore, geotropic)
was detected after a sudden homolateral latero-rota-
tion of the head in the supine position, indicative of a
Fig. 2. Vannucchi-Asprella liberatory manoeuvre for BP-
PV of right LSC: 1. patient is brought from seated to
supine position, with head straight; 2. head is briskly
turned 90° towards healthy side; 3. patient is brought
back to sitting position, keeping head to side, then slow-
ly turns it forward. This sequence is repeated for a min-
imum of 5 times.

mus directed towards the healthy side (and, there-


fore, inhibitory, due to the ampullofugal deflection of
the ampullary cupula) during execution of the single
steps of therapy.

Results

Of the 40 geotropic forms (Fig. 1), 30 were success- Fig. 3. Lempert’s liberatory manoeuvre for BPPV of right
fully treated with the Vannucchi-Asprella technique LSC: starting from supine position with head straight, 3
at the first session. The manoeuvre was repeated un- sudden 90° rotations of head towards healthy side are
imparted, rolling patient over each time and finally re-
til the horizontal nystagmus directed towards the turning him/her to seated position.
healthy side disappeared when changing from a sit-

12
TREATMENT OF LATERAL SEMICIRCULAR CANAL CANALOLITHIASIS

Fig. 4. Apogeotropic forms: liberatory manoeuvres car-


ried out.

Fig. 5. Gufoni’s liberatory manoeuvre for BPPV of right


geotropic LSC: patient, seated in centre of examination
probable transformation from apogeotropic to geot- couch, is briskly brought down to one side (healthy side
in geotropic forms, impaired side in apogeotropic
ropic. In these 6 patients, the Vannucchi-Asprella forms); head is then inclined downwards 45°.
technique was repeated 5 more times with disappear-
ance of the nystagmus in the passage from seated to
supine, and after latero-rotation of the head, and con-
sequently, eliminating the problem, later confirmed pert barbecue rotation technique. In 6 patients, at
during the diagnostic manoeuvre. In the other 2 pa- every 90° step, we observed a nystagmus directed to-
tients, whose geotropic nystagmus persisted after the wards the healthy side, indicating a further progres-
Vannucchi-Asprella manoeuvre had been carried out sion of the otoconial aggregate in an ampullofugal
10 times, treatment continued from the step with a direction. Verification with the Pagnini diagnostic
90° latero-rotated position of the head towards the manoeuvre confirmed that treatment had been suc-
healthy side with the Lempert technique, achieving cessful. One of these 7 patients, with an initially apo-
resolution in this way (Table I). geotropic form, when returning to the pathological
In 7 other cases of apogeotropic BPPV of the LSC, side (last step of the Lempert technique) suddenly
after failure of the other techniques, transformation presented a violent nystagmus towards the side in-
was attempted with the inverted Gufoni manoeuvre volved, and, therefore, geotropic, indicating that a
(Fig. 5): the patient, in a seated position, was rapidly transformation from apogeotropic in geotropic had
turned onto the pathological side. In all 7 patients, we occurred, but not a solution of the problem. This was
observed an apogeotropic horizontal nystagmus, in- later achieved by carrying out the Vannucchi-Asprel-
dicating an ampullofugal progression of the otolithic la technique 8 times (Table. I).
mass. It was decided to continue by swinging the pa- In all 55 patients, therapeutic success was achieved
tient’s legs onto the examination couch, with a Lem- during the first treatment session.

Table I. Geotropic and apogeotropic forms: number and type of manoeuvres carried out to achieve resolution of problem. V.A.:
Vannucchi-Asprella manoeuvre; inv. G.: inverted Gufoni manoeuvre; L.: Lempert manoeuvre.

Geotropic forms Apogeotropic forms

16 cases: solution after 3-4 V.A. manoeuvres 6 cases: solution after 5-6 V.A. manoeuvres

6 cases: solution after 5-6 V.A. manoeuvres 2 cases: solution with L. after transformation
in geotropic with V.A.

8 cases: solution after 8-10 V.A. manoeuvres 6 cases: solution with inv. G. followed by L.

10 cases: solution after 3-4 V.A. manoeuvres 1 case: solved with 8 V.A. manoeuvres after
followed by L. manoeuvre transformation in geotropic with inv. G. + L.

13
G. ASPRELLA LIBONATI ET AL.

Discussion The results described in a later report show a 90%


cure rate in these cases.
Over the last few years, there has been a proliferation In the same year, Vannucchi and Asprella 14 proposed
of therapeutic proposals regarding the treatment of a variant of the barbecue rotation manoeuvre: from a
BPPV of the LSC. supine position, the patient rapidly turns his/her
After early attempts at mobilisation of the otolithic head 90° towards the healthy side; then, while keep-
mass with head shaking in the supine position 6, ing the head turned, he/she returns to a seated posi-
showing unsatisfactory results, other Authors 7-9, tion and brings the head back in axis with the body;
over the next few years, suggested rehabilitation and, finally, he/she returns to the supine position.
techniques, defined as “barbecue rotation”. The lat- This sequence is repeated at least 5 times. The fol-
ter are based on the principle of exerting an am- lowing year, Asprella, Libonati and Gufoni 16 report-
pullofugal impetus to the otolithic mass in the canal ed that 3 cases out of 4 treated with this method were
by having the supine patient carry out rapid head ro- successfully solved. Using the same technique, Gal-
tations towards the healthy side, in single 90° steps, letti et al. 15 reported a 100% cure rate in a study on
in order to exploit the inertial lag of the otoconia, 10 patients (8 geotropic and 2 apogeotropic forms).
free to float in the canal endolymph. The overall an- In 1999, Asprella et al. 16 proposed a mixed liberato-
gle of rotation varied from 180° to 360°. In 1994, ry technique in which three rapid positionings were
Vannucchi et al. 10 proposed an innovative treatment followed by a brief forced recumbent position.
technique for BPPV of the LSC. Convinced that the In that same year, Mosca 17 published a personal ther-
pathogenic mechanism was engendered by apeutic approach, outlining a variant for the apo-
canalolithiasis, the Authors set up a procedure based geotropic forms and reporting success in 83% of cas-
on slow gravitational sedimentation of the otolithic es.
particles outside the non-ampullary segment of the A review of the literature, therefore, reveals a con-
LSC. The method, which is simple and applicable in siderable variety of rehabilitation manoeuvres, each
any patient, consists in forced immobility on the theoretically valid, aimed at achieving the am-
healthy side for at least 12 hours, in order to main- pullofugal endocanalar progression ampullofugal of
tain the simple segment of the LSC in a vertical po- the otoconial detritus, at times with angular accelera-
sition, with the non-ampullary aperture facing tions (barbecue rotation techniques), at times with
downwards; verification is effected after 72 hours. sudden linear accelerations (Gufoni and Mosca liber-
The Authors using the newly proposed technique in atory techniques), at times through slow gravitation-
13 patients, reported a cure rate of BPPV of the LSC al sedimentation (Vannucchi FLP), or, even, with
in 93% of cases. combined methods (Asprella liberatory manoeuvre).
In 1995 11, Epley proposed a technique of canaliths None of the techniques proposed, so far, have, how-
repositioning for BPPV of the LSC, without, howev- ever, led to a complete solution, in every case, at the
er, supplying a study documenting his results. first session, particularly as far as concerns the apo-
In 1995 12, Fife reported findings in four patients suf- geotropic forms.
fering from BPPV of the LSC, unsuccessfully treated Despite the wide range of treatment techniques avail-
with the Baloh manoeuvre. able, we prefer manoeuvres that are both well toler-
In 1997, Vannucchi et al. 13 verified the efficacy of the ated by the patient and effect a prompt solution. In-
therapeutic technique entailing a forced liberatory po- deed, for the geotropic forms, we usually prefer bar-
sition lying on the healthy side (FLP), comparing the becue rotation techniques as proposed by Vannucchi-
results obtained in three groups of patients: 1) 35 Asprella and Lempert. For apogeotropic forms,
treated with FLP; 2) 24 treated with head shaking in a transformation into geotropic was achieved in some
supine position; 3) 15 in whom no therapy was ef- cases, using the Vannucchi-Asprella manoeuvre to-
fected. In the first group, the Authors reported a solu- wards the healthy side. The line of conduct was cho-
tion of BPPV of the LSC, in 72 hours, in over 90% of sen in order to apply sudden, repeated angular accel-
the cases, vs 17% in the second group and 26% in the erations to the lateral semicircular canal involved and
untreated patients; furthermore, they reported a statis- its content (endolymphatic column and otolithic
tical significance in the therapeutic results of FLP. mass). Due to the inertial lag of the otoliths, the spe-
In 1998, Gufoni 14 proposed a new technique: starting cific weight of which is greater than that of the en-
from a seated position with the patient’s legs dan- dolymph, a gradual progression of the former in the
gling from the side of the examination couch, the pa- opposite direction from the rotation imparted to the
tient is asked to lie down rapidly on one side (on the head with the liberatory manoeuvre is thus obtained,
healthy side in the geotropic form, on the pathologi- exactly in the same way as in the geotropic forms, the
cal side in the apogeotropic form); the head is then only difference being a different point of endocanalar
turned downwards by 45°, waiting 2-3 minutes; fi- departure of the otoconia (from the ampullary seg-
nally, the patient is returned to the starting position. ment in the apogeotropic forms, from the non-am-

14
TREATMENT OF LATERAL SEMICIRCULAR CANAL CANALOLITHIASIS

pullary segment in the geotropic forms). In other made bearing in mind the “physical” needs of the pa-
words, in turning the head, and, therefore, the LSC, tient; albeit, we also stress the importance of check-
clockwise, the otoconial detritus proceeds in a coun- ing, during therapy, the effective ampullofugal pro-
terclockwise direction, and vice versa. gression of the otolithic mass by means of VNS mon-
This explains the sudden cure in some of the apo- itoring of the nystagmus evoked, using the well-
geotropic forms (6 cases) after repeating the Vannuc- known laws of Ewald in the interpretation.
chi-Asprella manoeuvre, towards the healthy side,
several times. In the other initially apogeotropic
forms, it was necessary to combine the different lib- Conclusions
eratory techniques in various ways (Vannucchi-As-
prella + Lempert; inverted Gufoni + Lempert) in or- VNS monitoring of the nystagmus during treatment
der to reach a complete solution in the first session, for BPPV due to canalolithiasis of the LSC, in over-
by means of VNS monitoring of the ampullofugal coming the rigid schematism of the manoeuvres pre-
progression of the otoconial mass. viously proposed in the literature, allows the rehabil-
On the grounds of our experience, we, therefore, pro- itation programme to be adapted step by step to the
pose that, on the basis of our knowledge of the dif- individual case, thus leading always to a complete
ferent rehabilitation techniques, the choice should be solution during the first treatment session.

10
References Vannucchi P, Giannoni B, Giuffreda P, Paradiso P, Pagnini
P. The therapy of benign paroxysmal positional vertigo of
1
Cipparrone L, Corridi G, Pagnini P. Cupulolitiasi. In: V the horizontal semicircular canal. In: Versino M, Zambar-
Giornata Italiana di Nistagmografia Clinica. Nistagmo- bieri D, editor. International Workshop on Eye Movements.
grafia e patologia vestibolare periferica. Milano: C.S.S. Pavia: Fondazione IRCCS; 1994. p. 321-4.
Boots-Formenti;1985. p. 36-53. 11
Epley JM. Positional vertigo related to semicircular
2
Pagnini P, Nuti D, Vannucchi P. Benign paroxysmal vertigo canalithiasis. Otolaryngol Head Neck Surg 1995;112:154-
of the horizontal canal. ORL J Otorhinolaryngol Relat Spec 61.
1989;51:161-70. 12
Fife TD. Horizontal canal benign positional vertigo. Ad-
3
Ewald R. Physiologische Untersuchungen über das Endor- vancing the science of vestibular diagnostics. ENG Report.
gan des Nervous Octavus. Weisbaden: Bergmann; 1892. Schaumburg: ed. ICS Medical; 1995. p. 1-4.
13
4
Pagnini P, Vannucchi P, Nuti D. Le nystagmus apo- Vannucchi P, Giannoni B, Pagnini P. Treatment of horizon-
geotropique dans la vertige paroxystique positionelle be- tal semicircular canal benign paroxysmal positional verti-
nign du canal semicirculaire horizontal. La Revue d’O- go. J Vestib Res 1997;7:1-6.
14
toneurologie Française 1994;12:304-7. Vannucchi P, Giannoni B. La terapia della vertigine po-
5
Nuti D, Vannucchi P, Pagnini P. Benign paroxysmal posi- sizionale del canale semicircolare laterale. Tecniche a con-
tional vertigo of the horizontal canal: a form of canalolithi- fronto. In: VII Giornata di Vestibologia Pratica. Milano:
asis with variable clinical features. J Vestib Res C.S.S Formenti; 1998. p. 61-73.
15
1996;6:173-84. Galletti F, Freni F, Leo L. Terapia della VPPB da litiasi del
6 canale semicircolare orizzontale. In: XVIII Giornate Italia-
Vannucchi P, Giannoni B, Nuti D. La cupulolitiasi del ca-
ne di Otoneurologia. Aspetti diagnostici riabilitativi della
nale semicircolare orizzontale: aspetti clinici. In: XII Gior-
nata Italiana di Nistagmografia Clinica. La cupulolitiasi. patologia vestibolare: stato dell’arte. Milano: Grunenthal-
Milano: C.S.S Formenti; 1992. p. 81-91. Formenti; 2001. p. 163-72.
16
7
Asprella Libonati G, Gufoni M. Vertigine parossistica da
Baloh RW, Jacobson K, Honrubia V. Horizontal semicircu- CSL: manovre di barbecue ed altre varianti. In: XVI Gior-
lar canal variant of benign positional vertigo. Neurology nate Italiane di Otoneurologia. Revisione critica di venti
1993;43:2542-9.
anni di vertigine parossistica posizionale benigna (VPPB).
8
Lempert T. Horizontal benign positional vertigo. Neurolo- Milano: C.S.S Formenti; 1999. p. 321-36.
gy [Letter] 1994;44:2213-4. 17
Mosca F. La vertigine parossistica da canale laterale. Pro-
9 posta di un metodo di trattamento. Acta Otorhinolaryngol
Baloh RW. Horizontal benign positional vertigo. Neurolo-
gy [Reply]1994;44:2213-4. Ital 1999;1:144-9.

■ Received April 15, 2002.


Accepted August 2, 2002.

■ Address for correspondence: Dr. G. Asprella Libonati,


Unità Operativa di Otorinolaringoiatria e Chirurgia Cervi-
co-Facciale, Presidio Ospedaliero, 75100 Matera, Italy.
Fax: +39 0835 243381. E-mail: asprella@tin.it

15