PO Box 13305 · Portland, OR 97213 · fax: (503) 229-8064 · (800) 837-8428 · [email protected] · WWW.VESTIBULAR.ORG Benign Paroxysmal Positional Vertigo (BPPV) By Timothy C. Hain, MD, Northwestern University Medical School, Chicago, Illinois; and the Vestibular Disorders Association Benign paroxysmal positional vertigo membrane in the utricle and collecting (BPPV) is the most common disorder in one of the semicircular canals. of the inner ear’s vestibular system, 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 nystagmus (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: Inner ear 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 dizziness 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 ears 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 electronystagmography (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. Epley maneuver 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