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Benign Paroxysmal Positional (BPPV) By Timothy C. Hain, MD, Northwestern University Medical School, Chicago, Illinois; and the Vestibular Disorders Association

Benign paroxysmal positional vertigo membrane in the and collecting (BPPV) is the most common disorder in one of the . of the inner ’s , When the head is still, gravity causes which is a vital part of maintaining the otoconia to clump and settle balance. BPPV is benign, meaning that (Figure 1). When the head moves, the it is not life-threatening nor generally otoconia shift. This stimulates the progressive. BPPV produces a cupula to send false signals to the sensation of spinning called vertigo brain, producing vertigo and triggering that is both paroxysmal and (involuntary eye positional, meaning it occurs suddenly movements). and with a change in head position.

Why does BPPV cause vertigo? The vestibular organs in each ear include the utricle, saccule, and three semicircular canals. The semicircular canals detect rotational movement. They are located at right angles to each other and are filled with a fluid called endolymph. When the head rotates, endolymphatic fluid lags behind because of inertia and exerts pressure against the cupula, the Figure 1: anatomy. Otoconia migrate sensory receptor at the base of the from the utricle, most commonly settling in the canal. The receptor then sends posterior semicircular canal (shown), or more impulses to the brain about the head’s rarely in the anterior or horizontal semicircular canals. The detached otoconia shift when the movement. head moves, stimulating the cupula to send false signals to the brain that create a sensation of vertigo. BPPV occurs as a result of otoconia, © Vestibular Disorders Association. Image adapted tiny crystals of calcium carbonate that by VEDA with permission from T. C. Hain. are a normal part of the inner ear’s anatomy, detaching from the otolithic Types of BPPV

© Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 1 of 10 Subtypes of BPPV are distinguished by health hazard due to an increased risk the particular semicircular canal of falls associated with and involved and whether the detached imbalance. otoconia are free floating within the affected canal (canalithiasis) or Causes attached to the cupula (cupulothiasis). BPPV is the most common vestibular BPPV is typically unilateral, meaning it disorder; 2.4% of all people will occurs either in the right or left ear, experience it at some point in their although in some cases it is bilateral, lifetimes.1 BPPV accounts for at least meaning both are affected. The 20% of diagnoses made by physicians most common form, accounting for who specialize in dizziness and 81% to 90% of all cases, is vestibular disorders, and is the cause canalithiasis in the posterior of approximately 50% of dizziness in semicircular canal.1 older people.2

Symptoms The most common cause of BPPV in In addition to vertigo, symptoms of people under age 50 is head injury and is BPPV include dizziness (light- presumably a result of concussive force headedness), imbalance, difficulty that displaces the otoconia. In people concentrating, and nausea. Activities over age 50, BPPV is most commonly that bring on symptoms can vary in idiopathic, meaning it occurs for no each person, but symptoms are known reason, but is generally associated precipitated by changing the head’s with natural age-related degeneration of position with respect to gravity. With the otolithic membrane. BPPV is also the involvement of the posterior associated with migraine3 and ototoxicity. semicircular Viruses affecting the ear (such as those canal in classic BPPV, common causing vestibular neuritis) and Ménière’s problematic head movements include disease are significant but unusual looking up, or rolling over and getting causes. Occasionally BPPV follows out of bed. surgery as a result of the trauma on the inner ear during the procedure combined BPPV may be experienced for a very with a prolonged supine (laying down short duration or it may last a lifetime, face-up) position.4 BPPV may also with symptoms occurring in an develop after long periods of inactivity. intermittent pattern that varies by duration, frequency, and intensity. It is not considered to be intrinsically life- threatening. However, it can be tremendously disruptive to a person’s work and social life, as well as pose a

© Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 2 of 10 the equipment used is capable of measuring vertical eye movements. A physician may also order radiographic imaging such as a magnetic resonance imaging scan (MRI) to rule out other problems such as a stroke or brain tumor, but such scans are not helpful in diagnosing BPPV.5 In addition, a physician may order auditory tests to Figure 2a: Canalith repositioning help pinpoint a specific cause of BPPV, procedure (CRP) for right-sided BPPV. such as Ménière’s disease or Steps 1 & 2 of CRP are identical to the labyrinthitis. Dix-Hallpike maneuver used to elicit nystagmus for diagnosis. The patient is Treating BPPV with in-office particle moved from a seated supine position; her repositioning head maneuvers head is then turned 45 degrees to the Recommended treatment for most right and held for 15-20 seconds. forms of BPPV employs particle

repositioning head maneuvers that Diagnosis move the displaced otoconia out of the BPPV is diagnosed based on medical affected semicircular canal. These history, physical examination, the maneuvers involve a specific series of results of vestibular and auditory patterned head and trunk movements (hearing) tests, and possibly lab work that can be performed in a health care to rule out other diagnoses. Vestibular provider’s office in about 15 minutes. tests include the Dix-Hallpike maneuver (see Figure 2a) and the Maneuvers for posterior canal Supine Roll test. These tests allow a BPPV physician to observe the nystagmus Particle repositioning head maneuvers elicited in response3 to a change in head4 5 are considered to be more effective position. The problematic semicircular than medication or other forms of canal can be identified based on the exercise-based therapy6 in treating characteristics of the observed posterior canal BPPV. However, even nystagmus. with successful treatment with such

maneuvers, BPPV recurs in about one- Frenzel goggles, especially of the type third of patients after one year, and in using a TV camera, are sometimes about 50% of all patients treated after used as a diagnostic aid in order to five years.7,8,9 magnify and illuminate nystagmus. If (ENG) is em- The canalith repositioning procedure ployed to observe nystagmus with (CRP) is the most common and position changes, it is important that

© Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 3 of 10 empirically proven treatment for arteries.11 In this case, persisting with posterior canal BPPV.1 Also called the the maneuver can lead to stroke. or the modified However, medical professionals can liberatory maneuver, CRP involves modify the exercises or use special sequential movement of the head into equipment so that the positions are four positions, with positional shifts attained by moving body and head spaced roughly 30 seconds apart simultaneously, thereby avoiding the (Figure 2a and 2b). Differing opinions problematic compression. exist about the benefits of using mastoid vibration during CRP,10 with a The Semont maneuver involves a recent evidence-based research procedure whereby the patient is review suggesting that it probably rapidly moved from lying on one side does not benefit patients.1 to lying on the other. Although many physicians have reported success Occasionally, when CRP is being treating patients with the Semont performed, neurological symptoms maneuver12 and support its use, more (e.g., weakness, numbness, and visual studies are required to determine its changes other than vertigo) occur, effectiveness.1 caused by compression of the vertebral

Figure 2b: Canalith repositioning procedure (CRP) for right-sided BPPV (continued). In Step 3 of the CRP, the head is turned 90 degrees until the unaffected left ear is facing the floor. The patient turns her body to follow her head, and the position is held for 15-20 seconds (Step 4); afterwards, she returns to a seated position (Step 5). The mirror image of these maneuvers can be performed for left-sided BPPV.

© Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 4 of 10 Maneuvers for horizontal canal 90˚ angles and pausing between each BPPV turn for 10 to 30 seconds. Other Because of the relative rarity of techniques such as the Gufoni horizontal canal BPPV, there are no maneuver and the Vannucchi-Asprella best practices established for liberatory maneuver have also been treatment maneuvers; however, the used to treat horizontal canal BPPV, most widely studied is the Lempert but additional well-supported clinical maneuver.1 This maneuver entails studies are needed to assess their moving the head through a series of effectiveness.1

Maneuvers for anterior canal BPPV There is no definitive treatment for anterior canal BPPV and no controlled studies of it have yet been completed. However, there is a logical modified maneuver for the anterior canal that is essentially a deep (exaggerated) Dix-Hallpike.13 Other proposed treatments employ reverse versions of the maneuvers used for posterior canal BPPV; for example, the reverse Semont (starting nose down and turned to the unaffected side), or the reverse Epley (again starting nose down). These treatments are geometrically reasonable, but require additional study to prove their efficacy.

Post-treatment considerations After successful treatment with particle repositioning maneuvers, residual dizziness is often experienced for up to three months. Whether post-treatment activity restrictions are useful has not been adequately studied.1 Nevertheless, many physicians recommend that their patients sleep in an elevated position with two or more pillows and/or not on the side of the treated ear, wear a cervical collar as a reminder to avoid quick head turns, and avoid exercises that involve looking up or down or head rotation (such as freestyle lap swimming). Such precautions are thought to help reduce the risk that the repositioned debris might return to the sensitive back part of the ear before it either adheres or is reabsorbed.

Other BPPV treatment options If head maneuvers don’t work, other treatment options include home-based exercise therapy, surgery, medication, or simply coping with the symptoms while waiting for them to resolve.

Vestibular rehabilitation home exercises Exercises performed at home are sometimes recommended. Brandt-Daroff exercises (Figure 3) involve repeating vertigo-inducing movements two to three times per

© Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 5 of 10 day for up to three weeks. After high as 95% for this strategy, receiving training from a doctor or insufficient evidence exists to physical therapist, a patient can recommend or refute its use. perform the exercises at home, but they are more arduous than office For horizontal canal BPPV that does treatments. With adherence to the not respond to head maneuvers, a prescribed schedule, Brandt-Daroff home treatment called forced exercises have been reported to prolonged positioning may be reduce vertiginous responses to head recommended. This requires a patient movements in 95% of cases.14 to rest in bed for at least 12 hours Patients performing Brandt-Daroff with the head turned toward the exercises may develop multicanal unaffected ear, permitting the BPPV as a complication and so should canaliths to gradually move out of the note any symptom changes to their canal. physicians.14 Finally, some physicians suggest that Another home exercise method is after office treatment, patients might daily self-administration of particle perform a daily self-canalith repositioning head maneuvers. One repositioning exercise at home to potential problem with this method is support the treatment’s continued that it may cause the condition to ffectiveness. However, such home worsen or initiate problems in another treatment probably does not affect the semicircular canal. Although one reoccurrence rate of posterior canal study15 has reported a cure rate as BPPV.16

Figure 3: Brandt-Daroff exercises. The patient sits upright, turns her head 45 degrees to the left, then lies down quickly on her right side for 10 seconds. After returning to an upright seated position, the patient turns her head 45 degrees to the right, lies down quickly on her left side for 10 seconds, then returns to an upright seated position.

© Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 6 of 10 Surgery Motion sickness medications are If head maneuvers and vestibular sometimes helpful in controlling the rehabilitation exercises are ineffective nausea associated with BPPV and are in controlling symptoms, surgery is sometimes used to help with acute sometimes considered. The goal of dizziness during particle repositioning surgery is to stop the inner ear from maneuvers. Otherwise, medications transmitting false signals about head are rarely considered beneficial. movement to the brain. Several Medication that suppresses vestibular surgical approaches are possible; function in the long term can interfere however, a procedure called posterior with a person making necessary canal plugging, also called fenestration adaptations to symptoms or remaining and occlusion of the posterior canal, is physically active because of side- preferable to other methods. These effects such as drowsiness. The include removing the balance organs American Academy of with a labyrinthectomy; severing the Otolaryngology—Head and Neck vestibular portion of the vestibulo- Surgery recommends against using cochlear nerve with a vestibular nerve vestibular suppressant medications, section, thus terminating all vestibular including antihistamines and signals from the affected side; or benzodiazapines, to control BPPV.5 severing the nerve that transmits Likewise, the American Academy of signals from an individual canal with a Neurology reports that there is no singular neurectomy. evidence supporting the routine use of medication to treat the disorder.1 Canal plugging stops the movement of particles within the posterior Wait-and-see semicircular canal with minimal impact Sometimes, adopting a “wait-and-see” on the rest of the inner ear. This approach is used for BPPV. Physicians procedure should not be considered often choose to monitor patients with until the diagnosis of BPPV is certain BPPV before attempting treatment and all maneuvers or exercises have because it frequently resolves without been attempted and found intervention.1 This may also be the ineffective.17 The surgery poses a approach taken with rare variants of small risk to hearing; some studies BPPV that occur spontaneously or show it to be effective in 85% to 90% after maneuvers and exercises. of individuals who have had no response to any other treatment,18 Coping strategies during this wait- although further research is and-see phase can involve modifying recommended.1 daily activities to help minimize symptoms. For example, this may Medication involve using two or more pillows

© Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 7 of 10 while in bed, avoiding sleeping on the are available at affected side, and rising slowly from www.neurology.org/cgi/content/full/7 bed in the morning. Other 0/22/ modifications include avoiding looking 2067/DC2. up, such as at a high cupboard shelf, or bending over to pick up something References from the floor. Patients with BPPV are 1. Fife TD, Iverson DJ, Lempert T, also cautioned to be careful when Furman JM, Baloh RW, Tusa RJ, positioned in a dentist’s or Hain TC, Herdman S, Morrow MJ, hairdresser’s chair, when lying supine, Gronseth GS. Practice parameter: or when participating in sports therapies for benign paroxysmal activities. positional vertigo (an evidence- based review): report of the Quality Finding diagnosis and treatment Standards Subcommittee of the for BPPV American Academy of Neurology. A list of vestibular disorder specialists Neurol. 2008;70:2067–2074. is available from the Vestibular 2. Froehling DA, Silverstein MD, Mohr Disorders Association (VEDA) Web site DN, Beatty CW, Offord KP, Ballard at www.vestibular.org/find-medical- DJ. Benign positional vertigo: help.php. This provider directory is incidence and prognosis in a annotated to indicate those specialists population-based study in Olmsted who are trained to perform canalith County, Minnesota. Mayo Clin Proc. repositioning maneuvers. 1991;66(6):596–601. 3. Ishiyama A, Jacobson KM, Baloh Additional resources RW. Migraine and benign positional Some helpful documents available from vertigo. Ann Otol Rhinol Laryngol. VEDA: 2000;109:377–380. Benign Paroxysmal Positional . 4. Atacan E, Sennaroglu L, Genc A, Vertigo (BPPV)—What You Need to Kaya S. Benign paroxysmal Know positional vertigo after (Book B-8) . Laryngoscope. . Inner Ear Surgeries Meant to 2001;111:1257–1259. Control Vertigo/Disequilibrium 5. Bhattacharyya N, Baugh RF, (Pub. T-6) Orvidas L, Barrs D, Bronston L, Cass Vestibular Rehabilitation: An . S, Chalian AA, Desmond AL, Earll Effective, Evidenced-Based JM, Fife TD, Fuller DC, Judge JO, Treatment (Pub. F-7) Mann NR, Rosenfeld RM, Schuring LT, Steiner RWP, Whitney SL, Video demonstrations of various Haidari J. Clinical practice guideline: particle repositioning head maneuvers benign paroxysmal positional

© Vestibular Disorders Association ◦ www.vestibular.org ◦ Page 8 of 10 vertigo. Arch Otolaryngol Head Neck 13. Kim YK, Shin JE, Chung JW. The Surg. 2008;139:S47–S81. effect of canalith repositioning for 6. Herdman SJ, ed. Vestibular anterior semicircular canal Rehabilitation. 3rd ed. Philadelphia: canalithiasis. Otorhinolaryngol Relat F.A. Davis Co.; 2007. Spec. 2005;67:56–60. 7. Nunez RA, Cass SP, Furman JM. 14. Hain TC. Home treatment of BPPV: Short and long-term outcomes of Brandt-Daroff exercises. Available canalith repositioning for benign at: www.dizziness-and- paroxysmal positional vertigo. Arch balance.com/disorders/bppv/bppv.h Otolaryngol Head Neck Surg. tml#home. Accessed Jan 26, 2009. 2000;122:647–652. 15. Radtke A, von Brevern M, Tiel- 8. Sakaida M, Takeuchi K, Ishinaga H, Wilck K, Mainz-Perchalla A, Adachi M, Majima Y. Long-term Neuhauser H, Lempert T. Self- outcome of benign paroxysmal treatment of benign paroxysmal positional vertigo. Neurol. positional vertigo: Semont 2003;60(9):1532–1534. maneuver vs Epley procedure. 9. Brandt T, Steddin S, Daroff RB. Neurol. 2004;63:150–152. Therapy for benign paroxysmal 16. Helminski JO, Janssen I, Hain TC. positioning vertigo, revisited. Daily exercise does not prevent Neurol. 1994;44(5):796–800. recurrence of benign paroxysmal 10. Hain TC, Helminski JO, Reis I, positional vertigo. Otol Neurol. Uddin M. Vibration does not improve 2008;29(7):976–981. results of the canalith repositioning 17. Parnes LS. Update on posterior maneuver. Arch Otolaryngol Head canal occlusion for benign Neck Surg. 2000;126:617–622. paroxysmal positional vertigo. 11. Sakaguchi M, Kitagawa K, Hougaku Otolaryngol Clin North Am. H, Hashimoto H, Nagai Y, Yamagami 1996;29(2):333–342. H, Ohtsuki T, Oku N, Hashikawa K, 18. Shaia WT, Zappia JJ, Bojrab DI, Matsushita K, Matsumoto M and Hori LaRouere ML, Sargent EW, Diaz RC. M. Mechanical compression of the Success of posterior semicircular extracranial vertebral artery during canal occlusion and application of neck rotation. Neurol. the dizziness handicap inventory. 2003;61(6):845–847. Otolaryngol Head Neck Surg. 12. Levrat E, van Melle G, Monnier P, 2006;134(3):424–430. Maire R. Efficacy of the Semont © 2009 Vestibular Disorders Association maneuver in benign paroxysmal VEDA’s publications are protected under copyright. positional vertigo. Arch Otolaryngol For more information, see our permissions guide at www.vestibular.org. Head Neck Surg. 2003;129(6):629– 633. This document is not intended as a substitute for professional health care.

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