| In
Benign Paroxysmal Positional Vertigo
(BPPV) dizziness is thought to be due
to debris which has collected within
a part of the inner ear. This debris
can be thought of as "ear rocks",
although the formal name is "otoconia".
Ear rocks are small crystals of calcium
carbonate derived from a structure in
the ear called the "utricle"
(figure1 ). While the saccule also contains
otoconia, they are not able to migrate
into the canal system. The utricle may
have been damaged by head injury, infection,
or other disorder of the inner ear,
or may have degenerated because of advanced
age. Normally otoconia appear to have
a slow turnover. They are probably dissolved
naturally as well as actively reabsorbed
by the "dark cells" of the
labyrinth (Lim, 1973, 1984), which are
found adjacent to the utricle and the
crista, although this idea is not accepted
by all (see Zucca, 1998, and Buckingham,
1999). |
 |
| BPPV
is a common cause of dizziness. About
20% of all dizziness is due to BPPV.
The older you are, the more likely it
is that your dizziness is due to BPPV,
as about 50% of all dizziness in older
people is due to BPPV. In a recent study,
9% of a group of urban dwelling elders
were found to have undiagnosed BPPV
(Oghalai, J. S., et al., 2000).The symptoms
of BPPV include dizziness or vertigo,
lightheadedness, imbalance, and nausea.
Activities which bring on symptoms will
vary among persons, but symptoms are
almost always precipitated by a change
of position of the head with respect
to gravity. |
 |
|
| Getting
out of bed or rolling over in bed are
common "problem" motions .
Because people with BPPV often feel
dizzy and unsteady when they tip their
heads back to look up, sometimes BPPV
is called "top shelf vertigo."
Women with BPPV may find that the use
of shampoo bowls in beauty parlors brings
on symptoms. An intermittent pattern
is common. BPPV may be present for a
few weeks, then stop, then come back
again. |
|
| WHAT CAUSES
BPPV? |
| The
most common cause of BPPV in people
under age 50 is head injury . There
is also an association with migraine
(Ishiyama et al, 2000). In older people,
the most common cause is degeneration
of the vestibular system of the inner
ear. BPPV becomes much more common with
advancing age (Froeling et al, 1991).
In half of all cases, BPPV is called
"idiopathic," which means
it occurs for no known reason. Viruses
affecting the ear such as those causing
vestibular neuritis , minor strokes
such as those involving anterior inferior
cerebellar artery (AICA) syndrome",
and Meniere's disease are significant
but unusual causes. Occasionally BPPV
follows surgery, where the cause is
felt to be a combination of a prolonged
period of supine positioning, or ear
trauma when the surgery is to the inner
ear (Atacan et al 2001). Other causes
of positional symptoms are discussed
here. |
|
| What doesn't
cause BPPV? |
| Gacek
has suggested that BPPV is due to recurrent
neuritis of the inferior vestibular
nerve (Gacek and Gacek, 2002). We think
that this is highly unlikely as BPPV
is very well explained by mechanical
consequences of loose debris within
the inner ear, and not at all consistent
with the usual picture of vestibular
neuritis. BPPV is also not caused by
psychological distress, and it is not
a side effect of medication. |
|
| HOW IS
THE DIAGNOSIS OF BPPV MADE? |
| Your
physician can make the diagnosis based
on your history, findings on physical
examination, and the results of vestibular
and auditory tests. Often, the diagnosis
can be made with history and physical
examination. Most other conditions that
have positional dizziness get worse
on standing rather than lying down (e.g.
orthostatic hypotension). Electronystagmography
(ENG) testing may be needed to look
for the characteristic nystagmus (jumping
of the eyes). It has been claimed that
BPPV accompanied by unilateral lateral
canal paralysis is suggestive of a vascular
etiology (Kim et al, 1999). For diagnosis
of BPPV with laboratory tests, it is
important to have the ENG test done
by a laboratory that can measure vertical
eye movements. A magnetic resonance
imaging (MRI) scan will be performed
if a stroke or brain tumor is suspected.
A rotatory chair test may be used for
difficult diagnostic problems. It is
possible but rather uncommon to have
BPPV in both ears (bilateral BPPV). |
|
| There
are some rare conditions that have symptoms
that resemble BPPV. Patients with certain
types of central vertigo such as the
spinocerebellar ataxias may have "bed
spins" and prefer to sleep propped
up in bed (Jen et al, 1998). These conditions
can generally be detected on a careful
neurological examination and also are
generally accompanied by a family history
of other persons with similar symptoms. |
|
| HOW MIGHT
BPPV AFFECT MY LIFE? |
| Certain
modifications in your daily activities
may be necessary to cope with your dizziness.
Use two or more pillows at night. Avoid
sleeping on the "bad" side.
In the morning, get up slowly and sit
on the edge of the bed for a minute.
Avoid bending down to pick up things,
and extending the head, such as to get
something out of a cabinet. Be careful
when at the dentist's office, the beauty
parlor when lying back having ones hair
washed, when participating in sports
activities and when you are lying flat
on your back. |
|
| HOW IS
BPPV TREATED? |
1-
Office Treatment
2- Home Treatment
3- Surgical Treatment |
|
| BPPV
has often been described as "self-limiting"
because symptoms often subside or disappear
within six months of onset. Symptoms
tend to wax and wane. Motion sickness
medications are sometimes helpful in
controlling the nausea associated with
BPPV but are otherwise rarely beneficial.
However, various kinds of physical maneuvers
and exercises have proved effective.
Three varieties of conservative treatment,
which involve exercises, and a treatment
that involves surgery are described
in the next sections. |
|
| OFFICE
TREATMENT OF BPPV: The Epley and Semont
Maneuvers |
| There
are two treatments of BPPV that are
usually performed in the doctor's office.
Both treatments are very effective,
with roughly an 80% cure rate, according
to a study by Herdman and others (1993).
If your doctor is unfamiliar with these
treatments, you can find a list of knowledgeable
doctors from the Vestibular Disorders
Association (VEDA). |
|
| The
maneuvers, named after their inventors,
are both intended to move debris or
"ear rocks" out of the sensitive
part of the ear (posterior canal) to
a less sensitive location. Each maneuver
takes about 15 minutes to complete.
The Semont maneuver (also called the
"liberatory" maneuver) involves
a procedure whereby the patient is rapidly
moved from lying on one side to lying
on the other. It is a brisk maneuver
that is not currently favored in the
United States. |
|
| The
Epley maneuver is also called the particle
repositioning, canalith repositioning
procedure, and modified liberatory maneuver.
It is illustrated in figure 2. It involves
sequential movement of the head into
four positions, staying in each position
for roughly 30 seconds. The recurrence
rate for BPPV after these maneuvers
is about 30 percent at one year, and
in some instances a second treatment
may be necessary. While some authors
advocate use of vibration in the Epley
maneuver, we have not found this useful
in a study of our patients (Hain et
al, 2000). Some authors also suggest
leaving out some of the positions in
the Epley maneuver, especially position
'D'. We suggest that you avoid therapy
using this methodology. |
|
| After
either of these maneuvers, you should
be prepared to follow the instructions
below, which are aimed at reducing the
chance that debris might fall back into
the sensitive back part of the ear. |
|
| INSTRUCTIONS
FOR PATIENTS AFTER OFFICE TREATMENTS
(Epley or Semont maneuvers) |
| 1-
Wait for 10 minutes after the maneuver
is performed before going home. This
is to avoid "quick spins,"
or brief bursts of vertigo as debris
repositions itself immediately after
the maneuver. Don't drive yourself home. |
|
| 2-
Sleep semi-recumbent for the next two
nights. This means sleep with your head
halfway between being flat and upright
(a 45 degree angle). This is most easily
done by using a recliner chair or by
using pillows arranged on a couch (see
figure 3). During the day, try to keep
your head vertical. You must not go
to the hairdresser or dentist. No exercise
which requires head movement. When men
shave under their chins, they should
bend their bodies forward in order to
keep their head vertical. If eyedrops
are required, try to put them in without
tilting the head back. Shampoo only
under the shower. |
|
| 3-
For at least one week, avoid provoking
head positions that might bring BPPV
on again. |
|
Use two pillows when you sleep.
Avoid sleeping on the "bad"
side.
Don't turn your head far up or far down. |
|
| Be
careful to avoid head-extended position,
in which you are lying on your back,
especially with your head turned towards
the affected side. This means be cautious
at the beauty parlor, dentist's office,
and while undergoing minor surgery.
Try to stay as upright as possible.
Exercises for low-back pain should be
stopped for a week. No "sit-ups"
should be done for at least one week
and no "crawl" swimming. (Breast
stroke is OK.) Also avoid far head-forward
positions such as might occur in certain
exercises (i.e. touching the toes).
Do not start doing the Brandt-Daroff
exercises immediately or 2 days after
the Epley or Semont maneuver, unless
specifically instructed otherwise by
your health care provider. |
|
| 4-
At one week after treatment, put yourself
in the position that usually makes you
dizzy. Position yourself cautiously
and under conditions in which you can't
fall or hurt yourself. Let your doctor
know how you did. |
|
| WHAT IF
THE MANEUVERS DON'T WORK? |
| These
maneuvers are effective in about 80%
of patients with BPPV (Herdman et al,
1993). If you are among the other 20
percent, your doctor may wish you to
proceed with the Brandt-Daroff exercises,
as described below. If a maneuver works
but symptoms recur or the response is
only partial (about 40% of the time
according to Smouha, 1997), another
trial of the maneuver might be advised.
The "habituation" exercises
are also sometimes useful in the situation
where all other maneuvers (Epley, Semont,
Brandt-Daroff) have been tried -- in
essence these consist of a more intense
and prolonged series of positional exercises.
When all maneuvers have been tried,
the diagnosis is clear, and symptoms
are still intolerable, surgical management
(posterior canal plugging) may be offered. |
|
| BPPV
often recurs. About 1/3 of patients
have a recurrence in the first year
after treatment, and by five years,
about half of all patients have a recurrence
(Hain et al, 2000; Nunez et al; 2000).
If BPPV recurs, in our practice we usually
retreat with one of the maneuvers above,
and then follow this with a once/day
set of the Brandt-Daroff exercises. |
|
| In
some persons, the positional vertigo
can be eliminated but imbalance persists.
In these persons it may be reasonable
to undertake a course of generic vestibular
rehabilitation, as they may still need
to compensate for a changed utricular
mass or a component of persistent vertigo
caused by cupulolithiasis. Fujino et
al (1994) reported conventional rehab
has some efficacy, even without specific
maneuvers. |
|
| HOME TREATMENT
OF BPPV |
| BRANDT-DAROFF
EXERCISES |
|
| The
Brandt-Daroff Exercises are a method
of treating BPPV, usually used when
the office treatment fails. They succeed
in 95% of cases but are more arduous
than the office treatments. These exercises
are performed in three sets per day
for two weeks. In each set, one performs
the maneuver as shown five times. |
|
| 1 repetition
= maneuver done to each side in turn
(takes 2 minutes) |
|
| Suggested
Schedule for Brandt-Daroff exercises. |
|
| Time |
Exercise |
Duration |
| Morning |
5 repetitions |
10 minutes |
| Noon |
5 repetitions |
10 minutes |
| Evening |
5 repetitions |
10 minutes |
|
|
| Start
sitting upright (position 1). Then move
into the side-lying position (position
2), with the head angled upward about
halfway. An easy way to remember this
is to imagine someone standing about
6 feet in front of you, and just keep
looking at their head at all times.
Stay in the side-lying position for
30 seconds, or until the dizziness subsides
if this is longer, then go back to the
sitting position (position 3). Stay
there for 30 seconds, and then go to
the opposite side (position 4) and follow
the same routine. |
|
| These
exercises should be performed for two
weeks, three times per day, or for three
weeks, twice per day. This adds up to
52 sets in total. In most persons, complete
relief from symptoms is obtained after
30 sets, or about 10 days. In approximately
30 percent of patients, BPPV will recur
within one year. If BPPV recurs, you
may wish to add one 10-minute exercise
to your daily routine (Amin et al, 1999).
The Brandt-Daroff exercises as well
as the Semont and Epley maneuvers are
compared in an article by Brandt (1994),
listed in the reference section. |
|
| The
home-Epley maneuver can also be used
very successfully to treat BPPV. They
also succeed in about 95% of cases within
one week. These are done in one set/day,
usually in the evening. (Radtke et al.
1999). Compared to the Brandt-Daroff
exercises, a disadvantage of the home-Epley
is that one must know which is the "bad"
side. |
|
| SURGICAL
TREATMENT OF BPPV |
| (POSTERIOR
CANAL PLUGGING) |
|
| If
the exercises described above 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 small
risk to hearing, but is effective in
about 90% of individuals who have had
no response to any other treatment.
Only about 1 percent of our BPPV patients
eventually have this procedure done.
Surgery should not be considered until
all three maneuvers/exercises (Epley,
Semont, and Brandt-Daroff) have been
attempted and failed. See the article
by Parnes (1990, 1996) in the references
for more information. |
|
| There
are several alternative surgeries. Dr
Gacek (Syracuse, New York) has written
extensively about singular nerve section.
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
canal plugging procedure. 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) |
|
| There
are several surgical procedures that
we feel are inadvisable for the individual
with intractable BPPV. Vestibular nerve
section, while effective, eliminates
more of the normal vestibular system
than is necessary. Labyrinthectomy and
sacculotomy are also both generally
inappropriate because of reduction or
loss of hearing expected with these
procedures. |
|
| ATYPICAL
BPPV |
| Lateral
Canal BPPV, Anterior Canal BPPV, Cupulolithiasis,
Vestibulolithiasis, Multicanal patterns |
|
| There
are several rarer variants of BPPV which
may occur spontaneously as well as after
the Brandt-Daroff maneuvers or Epley/Semont
maneuvers. They are mainly thought to
be caused by migration of otoconial
debris into canals other than the posterior
canal, the anterior or lateral canal.
There is presently no data reported
as to the frequency and extent of these
syndromes following treatment procedures.
It is the author's estimate that they
occur in roughly 5% of Epley maneuvers
and about 10% of the time after the
Brandt-Daroff exercises. In nearly all
instances, with the exception of cupulolithiasis,
these variants of BPPV following maneuvers
resolve within a week without any special
treatment, but when they do not, there
are procedures available to treat them. |
|
| In
clinical practice, atypical BPPV arising
spontaneously is first treated with
maneuvers as is typical BPPV, and the
special treatments as outlined below
are entered into only after treatment
failure. When atypical BPPV follows
the Epley, Semont or Brandt-Daroff maneuvers,
specific exercises are generally begun
as soon as the diagnosis is ascertained.
In patients in whom the exercise treatment
of atypical BPPV fails, especially in
situations where onset is spontaneous,
additional diagnostic testing such as
MRI scanning may be indicated. The reason
for this is to look for other types
of positional vertigo. |
|
| Lateral
canal BPPV is the most common atypical
BPPV variant, accounting for about 3-9
percent of cases (Korres et al, 2002).
Most cases are seen as a consequence
of an Epley maneuver. It is diagnosed
by a horizontal nystagmus that changes
direction according to the ear that
is down. |
|
| Anterior
canal BPPV is also rare, and a recent
study suggested that it accounts for
about 2% of cases of BPPV (Korres et
al, 2002). It is diagnosed by a positional
nystagmus with components of downbeating
and torsional movement on taking up
the Dix-Hallpike position, or a nystagmus
that is upbeating and torsional when
sitting up from the Dix-Hallpike. There
are a number of different suggestions
in the literature about the direction
of the torsional quick phase in anterior
canal BPPV. In our view, the nystagmus
during the Dix-Hallpike to one side
is most likely due to excitation of
the anterior canal on the opposite side.
This should cause downbeating nystagmus
as well as torsional nystagmus with
a quick-phase towards the disturbed
ear. Thus the direction of the torsional
component during the down-phase of the
Dix-Hallpike tells you which is the
bad ear. Anterior canal BPPV can be
provoked from the opposite ear to the
side of the Dix-Hallpike maneuver --
in other words, if you get dizzy to
the right side, the problem ear might
be the left. Some authors have suggested
that because the anterior canals are
oriented so that parts are near the
saggital plane, anterior canal BPPV
can be provoked with a Dix-Hallpike
maneuver to either side as well as in
the "head hanging" position
(Bertholon et al, 2002). The upbeating
nystagmus on sitting may be very persistent
as the debris settles on the cupula
of the anterior canal. Anterior canal
BPPV is probably rare because the anterior
canal is normally the highest part of
the ear. Debris would naturally tend
to fall out of the posterior half of
the anterior canal. From the geometry
of the ear, it would seem likely that
anterior canal BPPV might occasionally
result as a complication of the Epley
maneuver. |
|
| Debris
might also be temporarily located in
the common crus area, which is the shared
canal between the anterior and posterior
canal. Should debris be present in the
common cruse, one would expect a purely
torsional nystagmus. During the down
phase of the Dix-Hallpike, the torsional
nystagmus should beat away from the
bad ear. During the up phase of the
Dix-Hallpike, the torsional nystagmus
should beat towards the bad ear. |
|
| Cupulolithiasis
is a condition in which debris is stuck
to the cupula of a semicircular canal,
rather than being loose within the canal.
Cupulolithiasis is not a treatment complication,
but rather is part of the spectrum of
BPPV. The mechanistic hypothesis is
based on pathological findings of deposits
on the cupula made by Schuknecht and
Ruby in three patients who had BPPV
during their lives (Schuknecht 1969;
Schuknecht et al. 1973). Moriarty and
colleagues found similar deposits in
28% of 566 temporal bones (Moriarty
et al. 1992). Schuknecht pointed out
that cupulolithiasis hypothesis fails
to explain the usual characteristic
latency and burst pattern of BPPV nystagmus
as well as remissions (Schuknecht et
al. 1973). Rather, cupulolithiasis should
result in a constant nystagmus. This
pattern is sometimes seen (Smouha et
al. 1995). Cupulolithiasis might theoretically
occur in any canal -- horizontal, anterior
or vertical, each of which might have
it's own pattern of positional nystagmus.
Some authors hold that both the cupulolithiasis
and canalithiasis hypotheses may be
correct (Brandt et al. 1994). If cupulolithiasis
is suspected, it seems logical to treat
with either the Epley with vibration,
or alternatively, use the Semont maneuver.
There are no studies of cupulolithiasis
to indicate which strategy is the most
effective. |
|
| Vestibulolithiasis
is a hypothetical condition in which
debris is present on the vestibule-side
of the cupula, rather than being on
the canal side. For this theory, there
is loose debris, close to but unattached
to the cupula of the posterior canal,
possibly in the vestibule or short arm
of the semicircular canal. Pathologic
studies of BPPV have found roughly equal
amounts of fixed debris on either side
of the cupula (Moriarty et al. 1992),
suggesting that loose debris might also
be found on either side. For the vestibulolithiasis
mechanism, when the head is moved, stones
or other debris might shift from vestibule
to ampulla, or within the ampulla, impacting
the cupula. This mechanism would be
expected to resemble cupulolithiasis,
having a persistent nystagmus, but with
intermittency because the debris is
movable. Very little data is available
as to the frequency of this pattern,
and no data is available regarding treatment. |
|
| Multicanal
patterns. If debris can get into one
canal, why shouldn't it be able to get
into more than one ? It is common to
find small amounts of horizontal nystagmus
or contralateral downbeating nystagmus
in a person with classic posterior canal
BPPV. While other explanations are possible,
the most likely one is that there is
debris in multiple canals. |
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