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Benign Paroxysmal Positional Vertigo (BPPV) is the most common of vestibular disorders and the most easily treated. In most patients, it can be cured with a simple physical therapy maneuver. BPPV can affect people of all ages, although it is most common in folks over the age of 60.
BPPV occurs when small, microsized calcium crystals called otoconia become dislodged from their normal location on the utricle, one of the inner ear sensory organs. These otoconia are usually embedded in a gelatin like material on top of the utricle. If the otoconia become detached, they are free to flow in the fluid filled spaces of the inner ear, including the semicircular canals which sense the rotation of the head. If there are enough otoconia floating around, they can aggregate into a larger clump. Because they are heavy, they migrate into the lowest part of the inner ear, the posterior semicircular canal. Once in the semicircular canal, they may still move when the head changes position, such as looking up or down, over the shoulder, or when rolling over in bed. It is the movement of these stones that causes an unwanted flow of fluid in the semicircular canal even after the head has stopped moving. This leads to a false sense that the head and body are spinning around or that the world around you is spinning around.
Patients with BPPV usually experience vertigo when they turn over in bed, get in or out of bed, look up to a high shelf or put their head back in the shower. These are circumstances where there is a large change in the orientation of the head with respect to the pull of gravity. Patients often become imbalanced or unsteady when they get up from bed and try to walk and may even fall. They are occasionally quite ill with nausea, vomiting and other motion sickness like symptoms.
The onset of BPPV may be abrupt and frightening. Patients may even think they are having a stroke. Whenever they tilt or tip their head, they can experience extreme vertigo, imbalance, and may even fall out of bed. If they are up and around and tilt their head back or forward, they can fall to the ground. The usual course of the illness is a gradual lessening of symptoms over a period of weeks to months. Occasionally the symptoms can last for years.
While the hallmark of BPPV is episodic vertigo associated with changes in head position, many patients also have a mild degree of constant unsteadiness during the periods when they are also having the recurrent attacks of positional vertigo.
Causes of BPPV
In many patients, especially the elderly, there is no specific inciting event. As we get older, the otoconia are probably more easily sheared off from their normal positions stuck on the utricle. All of us certainly have a few of these microscopic stones floating around in our semicircular canals, but usually there are not enough of them to cause symptoms. Only when a large clump falls into one of the semicircular canals do the stones create their mischief.
In some patients, there may be a specific cause for the BPPV, including:
- Mild to moderate or severe head trauma
- Head in the same position for a long time, such as in the dentist chair, at the beauty shop or on strict bed rest
- Bike riding on rough trails
- High intensity aerobics
- Labyrinthine conditions – viral or vascular
- Ménières disease
- Vestibular migraines
The diagnosis of BPPV is made by the characteristic symptoms and also by observing the nystagmus – the jerking of the eyes that accompanies the severe vertigo patients experience when the position of their head is changed. By tilting a patient’s head way back at the end of an examining table, a doctor will try to provoke the symptoms to see the nystagmus for a thorough diagnosis.
The treatment of BPPV is based upon our specific knowledge of the disease. Bedside physical therapy maneuvers and programs of exercise have been designed with the goal of removing the stones from the semicircular canals. Once out of the semicircular canals, the stones are probably absorbed naturally over the course of days to weeks. There is always the risk of the stones falling back into the semicircular canal and getting stuck again. Once out, however, the otoconia usually don’t cause further problems. If the stones do fall back into the semicircular canal, the physical therapy can be repeated.
The physical therapy maneuver we usually use is called the Epley maneuver. First, while sitting up, the patients head is turned about 45 degrees to the side that normally provokes the vertigo. Then the patient is quickly laid down backwards with their head just over the edge of the examining table. This position usually provokes strong vertigo. The head is kept in this position for about 30 seconds and then turned 90 degrees to the opposite side. After another 30 seconds, the head and the body are turned together in the same direction so that the body is pointing towards the side, and the head is pointing down toward the ground at a 45 degree angle. After 30 seconds in this position, the patient is brought upright again. This is repeated as many as five or six times until neither vertigo nor nystagmus are elicited when the head is brought into the bad ear down position.
In some cases, a hand held vibrator is applied to the bone behind the bad ear to help dislodge the stones that may have become stuck on the walls of the semicircular canal.
- After the maneuver, the patient is asked to sit still with their head upright for ten-to-twenty minutes.
- Begin walking with caution
- Avoid putting head back, or bending far forward (for example, to tie shoes) for the remainder of the day
- Avoid sleeping on the side of the affected ear for several days
Usually no medications are required for BPPV unless the patient has severe nausea or vomiting. If extreme nausea does exist, anti-nausea medications can be prescribed before and/or after the treatment.
In about 70-80 percent of patients, a cure is immediate. In 20-30 percent, the symptoms recur within the first week and the patient should be treated again. Over the long term, BPPV recurs about half of the time. Usually the symptoms are less severe, and re-treatment is simple and effective. In patients with frequent recurrence, exercise programs can be prescribed so the patient can treat themselves.
In rare cases, a surgical procedure can be performed in which the posterior semicircular canal is plugged, preventing the otoconia from moving within the canal. While the surgical plugging procedure cures the problem, it carries some risk – including loss of hearing.
In some cases, one of the canals other than the posterior one is involved. If it is the lateral semicircular canal, slightly different maneuvers are used but still based upon the same principal of moving the stones out of the offending semicircular canal. Sometimes, simply lying with the bad ear up for 12 hours, while not a particularly exciting proposition, allows the stones to fall out of the canal and cures the condition.
BPPV of the anterior canal is exceedingly rare, as debris in this canal (located at the top of the inner ear) easily falls out on its own.
In many ways, the discovery of the mechanism of this simple treatment for BPPV is one of the most gratifying advances in the evaluation of the dizzy patient. BPPV can be diagnosed and treated successfully with no tests, no pills, no surgery and no special equipment.