Multiple Canal Benign Paroxysmal Positional Vertigo in an Elderly Patient with Labyrinthine Concussion: A Case Study

Abstract

Background and purpose:

50 million worldwide are reported to suffer from mild Traumatic Brain Injury (mTBI), or concussion.1  The cost of mTBI case management is estimated at over $60 billion annually in the United States alone.2  Persistent symptoms greater than 1 month, commonly known as post-concussion syndrome (PCS), can occur in approximately 44% of those concussed.3 Symptoms include 3 or more of the following: headache, dizziness, irritability, memory limitations, poor concentration, insomnia, and fatigue.4  

Benign paroxysmal positional vertigo (BPPV) can occur in up to 28% of those with concussion.5  Individuals with labyrinthine concussion have a higher chance of multiple canal BPPV as a sequalae.  Unilateral canal BPPV is estimated in 98.5% of cases, whereas multiple-canal BPPV is reported as 1.5% of cases.6 BPPV can cause symptoms and signs of dizziness, nausea, and disequilibrium that can be masked by symptoms of PCS.  BPPV is found 85% in the posterior canal and 15% in the lateral canal.  Given the overlap of symptoms in PCS and BPPV and the need for different treatment regimens, clinicians should carefully screen all concussed patients.  

Several cohort studies and case series have reported recovery rates from 50% to 100% with canalith repositioning techniques of the barbecue roll maneuver to treat lateral semicircular canal (geotropic form) and Epley’s maneuver to treat posterior semi-circular canal BPPV. 7    Canalith repositioning treatment (CRP) is a safe, low cost, and effective treatment for BPPV.7 The medical management of adults who are concussed varies among providers. This case report highlights an elderly male with a diagnosis of labyrinthine concussion after a mTBI seen in outpatient physical therapy for dizziness with multiple canal BPPV.

Case description:
A 70-year-old male presented in outpatient physical therapy (PT) 23 days after falling backwards off a ladder and hitting his head.  At the initial PT visit he reported since the fall the following symptoms: visual distances, memory difficulty, dizziness, balance problems, and inability to walk with stability. In the initial PT evaluation, due to the severity of symptoms, the patient was unable to participate in assessment of gait and other gross motor function.  The treating PT cleared him for oculomotor and vestibular system limitations, but he demonstrated a positive geotropic roll test for lateral canal involvement. He was treated with a barbeque roll technique for right side involvement. 

Outcomes:
and had a positive  geotropic roll test for lateral canal involvement.  He was treated with the barbeque roll technique for right side involvement. Although suspected combined posterior canal involvement, unable to tolerate further testing with Dix-Hallpike in visit 1. In visit 2, roll test was negative, and Dix-Hallpike positive in his left posterior canal.  He was treated with the Epley maneuver for left posterior canal involvement. In retest, both Dix-Hallpike and roll test with each bilaterally negative. Follow up PT assessment revealed symptoms were markedly better, sit to stand, walking and mobility improved by 99%.

Discussion: Investigation of early referral to physical therapy after mTBI is in question. Early diagnosing and treating BPPV after head injury may assist in medical cost reduction and potentially improved timeframe of symptom recovery.  Large scale RCT on testing for and treating adults with mTBI for BPPV as soon as medically cleared, is needed.
 






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