Dr. Li's recent paper about the value of mastoid oscillation and the canalith maneuver in treatment of benign positional vertigo1 (BPV) deserves comment. The main contention of the paper is that the use of a vibrator applied to the subject's mastoid during the canalith maneuver will usually "cure" BPV. Dr. Li states that he was motivated to write his paper in response to mine for which I did not use a vibrator2.

It is difficult to take the vibrator seriously. With no consideration of the physical situation involved in solid objects falling through a small fluid-filled, curved canal, Li and other authors have used different vibrators as available. They employ different frequencies of stimulation at different amplitudes in whatever manner each~author thinks they should be used. All are reported to "work. " I see no reason to believe that vibrators are other than a magic wand - a physical prop used to add mysticism to an implausible event to enhance its credibility.........The most interesting aspect of Li's paper is the untreated control group, NONE of whom improved. In contrast, the literature indicates that the majority of patients with BPV improve Spontaneously. Different authors use different time frames and descriptions, making direct comparisons difficult. In my study I found that the symptoms of 50% of controls were either all or essentially gone after one month............. I have no reason to believe that Dr. Li's findings are not sincere, yet clearly, there is a problem. Perhaps we are not looking at the same disease. Perhaps some other reason will explain the differences. We must try to resolve this discrepancy. Do other clinicians now find that BPV never improves spontaneously as Li reports? Time and further reports will tell. .......For the otolaryngologist who believes that this issue doesn't affect him or her I offer a final thought. It relates to the manner in which our specialty handles dizziness in general, but particularly the canalith maneuver. I believe that our credibility is damaged more than we realize when we embrace weird theories on flimsy evidence or adopt treatments without good reason. If the canalith story is characteristic of the depth of thought that we employ, is there any reason to respect us? Should the public trust us?

Dr. X, M.D., Ph.D.

I absolutely agree with Dr. X that it is difficult to take the mastoid vibrator seriously. Even the name invokes a few chuckles (which is why I prefer the term mastoid oscillation). The first few times I tried CRP, with mastoid oscillation, the patients and I laughed through the entire procedure, joking about the voodoo medicine we were performing. But to our surprise, almost everyone came back with incredulous stories of how they were completely cured of their problems. Their results were all the more extraordinary because they came after numerous physician consults combined with failed watchful waiting and/or oral vestibulosuppressant therapy.

From that point on we became a referral center for BPPV and have, to date, maintained at least a 95% "cure" rate (abolition of rotary nystagmus and symptoms). Since many of our patients were referred for CRP and expected to receive it, there was some difficulty in creating a control group. We were able to create this control group by staving off the procedure for a week or two rather than immediately performing CRP on the day of the patient's visit. This means that our "controls" reflect the a one week interval change of patients who presented with BPPV symptoms serious enough to warrant treatment.

Dr. X states that "NONE" of my patients in the untreated control group improved. This is not quite true. One patient in this group did report a marked improvement, however, classic nystagmus was found on Dix Hallpike testing. My time interval for reevaluation was one week. Had I used one month, or even six months, the my numbers would, of course, reflect more closely the spontaneous remission rate. I have also found that merely asking patients about their dizzy spells is quite inaccurate. BPPV patients learn to avoid activities that provoke dizziness. Detailed questioning is necessary and Dix Hallpike testing should be done to confirm improvement.

Consider the hypothetical controversy of treating a deep laceration with sutures vs. waiting for spontaneous closure. If you check the wounds from each group in a month or two, chances are that they would be healed, and one might conclude that sutures are worthless because wounds can close by themselves. However, if checked within a one week interval, the sutured vs. no treatment wound groups would differ vastly. The conclusion that sutures are worthwhile should be obvious. One must naturally develop criterion regarding depth of lacerations to be sutured; likewise, criterion regarding severity of vertigo and disability will determine which patients receive CRP.

As far as the comment on "weird theories" is concerned, I would agree that to an uneducated lay person, the idea that strapping on a oscillating contraption while being placed in various contortions would seem farfetched. However, there is a reasonable scientific basis for this procedure's success. I would also point out that every scientific advance has had its contingency of detractors. If we close our minds to progress we would live in a world without vaccines, antibiotics, electricity, etc. and perhaps still believe that the earth was flat.

The bottom line is that the technique of CRP with mastoid oscillation works well. From the time they leave the office, 95% of patients presenting with BPPV are immediately improved. They no longer need to live with horrible vertigo symptoms for weeks, months or years. They do not need to consult a multitude of physicians and waste health care dollars.

I challenge any physician to simply try the techniques of CRP with the use of a mastoid oscillator. My results should be easily reproducible.

Sincerely,

John Li, MD