What is benign paroxysmal positional vertigo?
Benign paroxysmal positional vertigo (BPPV) is characterized by sudden inappropriate sensation of motion that is triggered by certain provocative head positions. You will typically feel like the room is spinning and this is known as vertigo.
BPPV is the most common cause of vertigo in the United States. In addition, it is more common in women than men and in older people aged above 50 years. It is usually not a serious disorder except when is predisposes you to falls.
What causes benign paroxysmal positional vertigo?
BPPV usually follows head trauma that causes a disturbance inside your inner ear. Semi-circular canals are found inside your inner ear and contain fluids which move when you change the position of your body. There are small crystals known as otoliths that are located inside your inner ear which are responsible for the detection of motion of the fluids inside your semi-circular canals. Signals are then sent to the brain to regulate and maintain your balance.
In BPPV, these crystals get dislodged into the semi-circular canals which results in inappropriate signalling to your brain, giving you a false sense of motion when in fact you are not moving.
What are the signs and symptoms of benign paroxysmal positional vertigo?
The signs and symptoms of BPPV are typically sudden and result from a change in head position. The episode of vertigo usually lasts for about 20-30 seconds. In addition, during the episode of vertigo there will be an abnormal eye movement called nystagmus. Signs and symptoms of BPPV include:
- Sensation that the room is spinning (vertigo).
- Light-headedness.
- Nausea
- Vomiting
- Loss of balance during the episode of vertigo.
Making a diagnosis
Your doctor will take a detailed history from you to know more about your symptoms. After the history taking, your doctor will perform a physical examination to look for signs of BPPV. The standard clinical test for BPPV is Dix-Hallpike manoeuvre. This manoeuvre involves your doctor rapidly moving you from a sitting position to a supine position (lying down), with your head slightly turned to the right. After waiting for 30 seconds, you will be returned to a sitting position. Your doctor will examine your eyes throughout the manoeuvre to look for nystagmus. If no abnormality was found, then the manoeuvre is repeated on the left side. The history taking and the Dix-Hallpike manoeuvre is usually sufficient for the diagnosis of BPPV.
Laboratory and imaging tests are not required for the diagnosis of BPPV. However, these tests may be useful to rule out other disorders presenting with vertigo such as Meniere’s disease, vestibular neuritis, multiple sclerosis and intracranial space occupying lesion.
What are the treatments for benign paroxysmal positional vertigo?
The treatments available for BPPV include watchful waiting, vestibulosuppressant medications, canalith repositioning and surgery.
Watchful waiting
Since BPPV is a benign condition, it can resolve on its own in weeks to months. However, during this period of time you will be at increased risk of falls. In addition, you will feel very uncomfortable as you will be experiencing several episodes of vertigo and vomiting.
Vestibulosuppressant medications
These medications ma help to mask the problem but will not resolve it. It usually provides minimal relief and do not stop the vertigo. Examples of vestibulosuppressant medications include anticholinergics, antihistamines and benzodiazepines. Side effects of the medications include increased risk of falling due to grogginess and impaired memory.
Canalith repositioning procedure
This procedure is also known as Epley procedure. It is the first choice among the treatment options. This procedure is a simple, effective and non-invasive office treatment that can cure BPPV in 1-2 sessions. In experienced hands, it has a success rate of more than 95%.
If your right ear is affected, the Epley procedure is as follows:
- Your doctor will place you in a sitting position with your head turned towards the affected side.
- Your doctor will slowly bring your head down which is still turned towards the affected side. If you experience vertigo, your doctor will wait for it to stop before proceeding to the next step.
- Your doctor will ask you to turn your head even more towards the affected side without raising your head for 30 seconds.
- You will be asked to turn your head to the unaffected side and wait for 30 seconds.
- Your doctor will asked you to roll on your sides keeping your side turned to the unaffected side for 40 seconds.
- Your doctor will help you to regain a sitting position while your head is still turned towards the unaffected side.
- Finally you will be asked to turn our head towards the midline.
After the Epley procedure, a Dix-Hallpike manoeuvre is performed immediately after the test. If nystagmus is observed, the Epley procedure is repeated. In addition, you will be required to avoid agitation of the head for at least 2 days.
Surgical treatment
Surgical treatment is reserved for those in whom canalith repositioning procedure was not successful on several occasions. It is usually a last resort treatment as it carries risks or complications such as hearing loss and facial nerve damage. There are many surgical procedures that can be done but the most viable surgical option is posterior canal occlusion. After the surgery, you may experience balance difficulties for a few weeks to months which may be treated with vestibular rehabilitation.
Prognosis
BPPV can be treated effectively with the Epley procedure and it has a 95% success rate. BPPV is usually a benign problem but can become serious during the few seconds of vertigo due to balance difficulties. It can resolve on its own after weeks to months but this timeframe will be very uncomfortable and risky. The Epley procedure greatly diminishes the time taken to recover from BPPV compare when no treatment is given.
Source:
Li, J., 2020. Benign Paroxysmal Positional Vertigo Treatment & Management.
Li, J., 2020. Benign Paroxysmal Positional Vertigo Workup.
NHS. 2020. Vertigo.
Parveen, K. and Michael, C., 2017. Kumar & Clarks Clinical Medicine. 9th ed. The Netherlands: ELSEVIER.
