This blog is an advanced topic which shares my perspective in the ongoing debate among vestibular professionals about the existence of anterior canal BPPV.
Hint: It exists!
In the 2008 original BPPV clinical practice guidelines, anterior canal BPPV was stated to be a rare variation of BPPV.
In 2017, The BPPV Clinical Practice Guidelines were revised and published as a supplement to the March 2017 issue of the medical journal called Otolaryngology – Head and Neck Surgery.
However, the authors who updated the BPPV guideline stated that they removed “anterior canal BPPV” from the guideline, citing a question about its existence.
As a BPPV expert, I can assure you that anterior canal BPPV is a condition that I regularly treat.
Since it has been omitted from the revised BPPV clinical practice guidelines, I believe a lot of inexperienced providers are missing it.
How Does It Happen?
If you look at the anatomy of the vestibular semi-circular canals, you may notice the anterior canal is “up” in relation to the others. Therefore, most times that BPPV crystals start to go up into the anterior canal, they will just fall back down.
However, in my opinion, if there is sufficient momentum and/ or enough angular acceleration in the plane of the anterior canal, then the crystals can go up and over the arch of the anterior canal to lodge in there.
This is what causes Anterior canal BPPV!
Trauma
When trauma is involved, the anterior canal BPPV may result directly from the traumatic incident if there was enough force involved at a certain angle of the head. Some examples of trauma that can directly cause anterior canal BPPV are:
- Rollover car accident
- Hit your head on the dashboard during a rear-end car crash
- Fall forward to hit your face on furniture
- Fall forward to land on your face on the floor
Anterior Canal Conversion
Aside from a traumatic onset, I believe that many cases of anterior canal BPPV are caused by a “Canal Conversion.”
I most often see anterior canal BPPV in people who have had mild dizziness or vertigo for awhile and have never had proper care. They tell me they continued to live an active lifestyle until their symptoms got so bad that they consulted with me for care.
In my opinion, these cases occurred in the anterior canal by “converting” from the untreated posterior canal BPPV.
The crystals are usually free-floating and the canals are all connected within one ear, so it makes sense that certain activities can spread out the crystals into other canals.
Once the BPPV converts into anterior canal, that second error signal adds onto the posterior canal BPPV. Then having BPPV in both canals, the individual is so miserable that they decide to finally seek treatment.
How Does An Anterior Canal Conversion Occur?
There has to be enough momentum and angular acceleration to launch the crystals up and over the apex of the curve to lodge in the top part of the vestibular canal system.
Most of the time, it is suspected that any crystals that go up into the anterior canal will just fall back down and out. Therefore, in order for the crystals to lodge into the anterior canal and create anterior canal BPPV, there have to be enough force to propel them up and over.
There must be a circular motion creating momentum for crystals that were already loose in the posterior canal that moves them up and over the top to lodge to the anterior canal.
Activities That Cause Conversion
Here are some examples of activities that my patients have done while they had mild dizziness or vertigo. These activities took them “over the edge” and caused them to seek treatment.
When I examined them, I found they had both posterior and anterior canal BPPV in the same ear.
Common canal conversion activities fall under the categories of exercise, recreation, and routine hair care.
I believe the following activities most likely converted their mild dizziness and vertigo from posterior canal BPPV to anterior canal BPPV.
Exercise and Recreation:
- Back bending over a fitness ball to stretch out
- Doing backwards somersaults in the pool or the ocean
- Gymnastics, especially somersaults, cartwheels, handstands, backwards handsprings, back flips, and springboard stunts
- Tumbling
- Cheerleading
- Jiu Jitsu
- Mat Wrestling
- Headstands and handstands during yoga class, especially Ashtanga and Iyengar yoga styles
- Back flips off a diving board into a pool
- Back flips off a house boat into a lake
- Diving off a springboard, high dive, or cliff
- Bending way down to the floor to kiss a tiny puppy
Routine Hair Care:
I have noticed a trend of five specific types of hair care that men and women with mild dizziness often with their head upside down.
The following five activities often precede my finding of anterior canal BPPV:
- Hold your head upside down to put a towel on your head after a shower, then flip head back up
- Apply gel with your head upside down
- Spray hair with head upside down
- Blow dry hair upside down and shake head all around
- Comb / brush hair with head upside down
I described to one of my patients that shaking her head around while she is blow drying her hair, is like taking a leaf blower to the BPPV crystals inside her posterior canal and spreading them out all over her vestibular labyrinth.
It’s not surprising that certain exercises, recreational activities, and routine hair care take the vertigo symptoms “over the top” for my patients who have been living with tolerable vertigo for awhile.
How does Anterior Canal BPPV feel?
BPPV generally causes dizziness, imbalance, and positionally triggered vertigo or blurry vision. Symptoms are common with bending forward, but that can also be from posterior canal. Symptoms may also occur with your chin tipped down towards your chest for text messaging.
So if you tilt your chin down to type a text message and your vision gets blurry for a few seconds, then you could have anterior or posterior canal BPPV.
Many providers know how to treat posterior canal BPPV. If you have been treated for posterior canal BPPV and still have dizziness with certain movements, I suggest you seek out an advanced level vestibular provider who can assess and treat anterior canal BPPV.
Since anterior canal BPPV has been removed from the revised BPPV clinical practice guidelines, many novice practitioners may not even consider this as a possible cause of dizziness and vertigo. Yikes!
Disclaimer
This blog is provided for informational purposes only. The content and any comments by Dr. Kim Bell, DPT are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. The details of any case mentioned in this post represent a typical patient that Dr. Bell might see and do not describe the circumstances of a specific individual.
I am currently having a bout with BPPV and it started out mild then hit me like gang busters and I am wondering if I have crystals lodged in the anterior canal after reading your blog post on this.
I would continue my yoga practice on days that my mild symptoms seemed better, including headstand and full backbend. It came on when I was fully in a forward fold then came up and it was in the coming up that it hit.
Also, a few days later, after washing my hair, I was fully forward wrapping the towel around my hair and when I came up, it hit me hard.
Now, since then, this has been a particularly bad bout where I am challenged to do most anything.
So does anyone else have a feeling of jelly brain with dizziness?
I’m so glad I found this blog! I am a vestibular therapist as well and have treated a handful of patients with anterior canal BPPV. The most recent 2 felt it most with yoga. I learned back in 2011 about the Forward Particle Repositioning Maneuver from APTA’s Combined Sections and have used it since, finding it most effective. I do not understand why they took anterior canal out? Thank you so much for your blog…looking forward to reading more!
Hi Jessica,
I am so glad you found this blog! I find so many providers shy away from treating people with vertigo, because the learning curve is so steep.
Good for you for taking it on!
I like to use this page as a good reference for AC BPPV.
I am not sure why they took it out – except that the anatomy makes it very unlikely for BPPV crystals to get over top of the apex of the curve of the anterior canal, with a spontaneous BPPV onset.
Since most BPPV crystals that head upwards in that direction would naturally just fall back down, I suspect the authors dismissed it.
However, I have found that people who had a previous episode of vertigo, but continued to live their life with activities such as blow drying, toweling or styling their hair upside down, doing headstands in yoga, somersaults, back flips in the pool, etc tend to apply enough of a rotational force to get the crystals up over the apex into “the loft” of the vestibular system – which is my laymen’s term for the anterior canal.
In my experience, in the absence of trauma such as a rollover car accident or hard fall to floor landing on the face, it is unlikely that anterior canal will be the initial location of the BPPV.
Most of my anterior canal cases have occurred in what I suspect are “canal conversions” as I described above.
One of my recent anterior canal cases – the patient described that he had vertigo for awhile and then did a back flip in a pool. He could barely stand after that and he felt like he flipped 6 times in a row, but it was only one flip. I suspect that was the incident in which the crystals converted from posterior canal to anterior canal, where I found them.
I am glad that you are looking for it!
It is unfortunate that newly trained vestibular PT’s who only read the “revised” clinical practice guideline for BPPV will not think to look for it or treat it.
I encourage all BPPV therapists to read BOTH versions of the Clinical Practice Guidelines.
I hope that helps!
Keep up the good work, Jessica!
Sincerely,
Kim Bell, DPT
Could a rollercoaster ride with aggressive loops and speed cause this to occur as well?
Hi Angela,
Well, this is a very good question.
I would say that any activity that involves flipping or going upside down can convert the BPPV crystals from the more common locations to the anterior canal.
I hope that helps!
Sincerely,
Kim Bell, DPT
Can a test by a PT without treating it right away cause posterior canal crystals to move into the anterior canal?
I doubt it, unless they had you do a headstand, downward dog, full somersault, or back flip – going fully upside down.
Just lying back below horizontal and sitting back up should not cause that type of canal conversion.
This blog talks more about BPPV treatment.
You can also use this blog to search for a vestibular physical therapist.