Timothy C. Hain, MD • Page last modified: February 19, 2022
|Canal plugging for BPPV (rarely done)|
As a quick overview, surgical treatment for BPPV is very rarely done. Although effective (Mass et al, 2020), the frequency of surgical treatment has been dropping rapidly in favor of other treatments (Leveque et al, 2007). As of 2022, we (at Chicago Dizziness and Hearing) have not had any patients go for surgery for at least 10 years. Surgery should not be considered until all three maneuvers/exercises (Office Epley, Office Semont, Home Epley) have been attempted and failed. We also think a trial of vibration to the mastoid is reasonable.
Surgical treatment of BPPV is not easy -- your local ear doctor will probably have had no experience at all with this operation. Of course, it is always advisable when planning surgery to select a surgeon who has had as wide an experience as possible. Complications are rare (Rizvi and Gauthier, 2002), but nevertheless one should still think carefully about undergoing a procedure that has a 3% risk of unilateral hearing loss.
There are two types of surgery - -canal plugging and singular nerve section. Both are intended to deactivate the part of the ear that is causing dizziness, and leave the rest of the ear functioning.
Indications for surgery:
If the exercises for BPPV are ineffective in controlling symptoms, symptoms have persisted for a year or longer, and the diagnosis is very clear, a surgical procedure called "posterior canal plugging" may be recommended. Canal plugging blocks most of the posterior canal's function without affecting the functions of the other canals or parts of the ear. This procedure poses a substantial risk to hearing -- ranging from 3-20%, but is effective in about 85-90% of individuals who have had no response to any other treatment (Mass et al, 2020). The risk of the surgery to hearing derives from inadvertent breaking into the endolymphatic compartment while attempting to open the bony labyrinth with a drill. Sensibly, canal plugging for BPPV (note the first letter stands for "benign") is rarely undertaken these days due to the risk to hearing.
Alternatives to plugging.
Singular nerve section is the main alternative. Dr Gacek (Syracuse, New York) has written extensively about singular nerve section (Gacek et al, 1995). Interestingly, Dr. Gacek is the only surgeon who has published any results with this procedure post 1993 (Leveque et al, 2007). Singular nerve section is very difficult because it can be hard to find the singular nerve.
Dr. Anthony (Houston, Texas), advocates laser assisted posterior canal plugging. It seems to us that these procedures, which require unusual amounts of surgical skill, have little advantage over a conventional canal plugging procedure.
Don't do these surgical procedures for BPPV
There are several surgical procedures that are simply inadvisable for the individual with intractable BPPV. Vestibular nerve section, while effective, eliminates more of the normal vestibular system than is necessary. Similarly, transtympanic gentamicin treatment is inappropriate. Labyrinthectomy and sacculotomy are also both inappropriate because of reduction or loss of hearing expected with these procedures. Singular nerve section appears to be too difficult for most otologic surgeons.