I've been performing Semont and Epley procedures for 10 years with great success and I have a strong understanding of the differences between canal vs. cupulolithiasis. However, when a person has horizontal canal involvement, how do you localize the side and what is your recommendation for treatment? Also, what are the negative ramifications of performing these services on cash pay basis since we cannot bill the therapy codes unless a physician is present and we bill through him or her?
There are several rare variants of BPPV which may occur spontaneously or subsequent to, canalith repositioning therapy in confirmed cases of posterior canal BPPV. These deviants of BPPV may be caused by migration of otoconial debris into the anterior or lateral (horizontal) canals, rather than the ''target'' canal.
It is theoretically possible for many aberrant patterns of BPPV to occur from an interaction of debris in several canals, location of debris within the canal, and central adaptation patterns to lesions.
Lateral (horizontal) canal BPPV is the most common atypical variant, accounting for about 3 percent of cases. Most cases are seen as a consequence of canalith repositioning therapy
Lateral Canal BPPV is diagnosed by demonstration of a horizontal nystagmus that changes direction depending on the ''down'' ear. The nystagmus can be either always towards the ground (''geotrophic'') or always towards the sky
(''ageotrophic''). Nystagmus that is ageotrophic may be caused by debris that is further around the canal and closer to the ampulla, than is the case with geotrophic nystagmus.
When lateral (horizontal) canal BPPV follows a treatment maneuver, the ''bad'' ear is considered to be the same one with the posterior canal BPPV.
In idiopathic cases of geotrophic nystagmus, the ear with the lateral (horizontal) canal BPPV is assigned to the side with the stronger nystagmus. With ageotrophic nystagmus, the ear with lateral (horizontal) canal BPPV is assigned to the side with the weaker nystagmus. On occasion it will be necessary for the clinician to make a ''clinical judgment call'', integrating presenting complaints and other test data about which ear is diseased (such as hearing, fullness and the like). In situations where the affected side is unclear, it may be worthwhile to treat the more likely side first, and then switch to the other side if symptoms persist for more than a week.
I am unsure what the author meant by ''negative ramifications''. There is certainly nothing wrong with anyone expecting to be paid for professional services provided. The recipient (patient) of those services must be told in advance that payment is expected at the time of service and their insurance issues must be addressed promptly and with their direct input to the insurance company. Of course, whenever patients realize a personal financial obligation may be incurred for services provided, they may elect to cancel the appointment.
Dr. Henry Trahan
Dr. Trahan is a graduate of LSUHSC, Masters of Communicative Disorders. Graduate of the University of Florida, Doctor of Audiology
Assistant Professor of Audiology at the Arizona School of Health Sciences. Lead faculty for the 4 year AuD Residential program. Currently also teaching Vestibular Assessment Procedures and Balance Remediation in the ASHS AuD Distance Ed AuD program.
20 years private practice with significant involvement in assessment of vestibular disorders and vestibular rehabilitation.
Conducted numerous workshops and presentations in regards to Audiologists in private practice adding Vestibular Assessment and Vestibular Rehabilitation to their practices.