Positional Vertigo

Have you ever woken up and tried to get out of bed and got a sudden sensation that the room is spinning? You have to hold the furniture and walls just to get out of bed and take a few steps. After you stand in one position for a few minutes, the feeling passes.

This is the most common description given by patients with Benign Paroxysmal Positional Vertigo (BPPV). Also referred to simply as positional vertigo, BPPV is a common form of balance disturbance that originates in the inner ear. It is a brief, intense sensation of spinning that occurs when getting out of bed or turning your head too quickly. Although frightening, it is most often harmless.

HOW DOES A NORMAL VESTIBULAR SYSTEM WORK?

The inner ear houses the hearing organ (cochlea) and the balance organ, also called the vestibular system. The vestibular system is composed of the utricle, the saccule and three semicircular canals. The different structures of the vestibular system are all built in a similar manner. Very simply described, each structure is like a wired mini marshmallow in a Jello mold: they consist of nerve receptors that are embedded in a gelatinous mixture in which little calcium carbonate crystals float.

When the head changes direction, the change in gravity or velocity moves the crystals around in the gel and changes the pressure against the nerve receptors (imagine that Jello wobbling as you transfer it from the kitchen to the table). Each of the five vestibular system structures is oriented in a particular manner so that we can detect head position and motion in all different directions. When everything is working properly, the vestibular system helps us keep our balance whether we’re out walking, dancing the tango or doing a somersault.

WHAT IS BPPV?

Benign Paroxysmal Positional Vertigo (BPPV) is thought to be caused by the calcium carbonate crystals becoming disengaged from the gelatinous mixture and fall into the wrong space in the inner ear. The debris, called “otoconia,” composed of small crystals of calcium carbonate normally found in the utricle.

The crystals become dislodged from the utricle and move into one of the three semi-circular canals, most often the posterior canal.  Occasionally, the displaced crystals then cause abnormal stimulation of the nerve receptors when the head is moved in certain ways. This abnormal stimulation results in the perception of vertigo, or spinning. The reason why these crystals become disengaged and cause this condition is unknown about half of the time.

When there is a known cause for BPPV, it is commonly head injury or migraine. Traumatic head injury can mechanically jostle the crystals out of place; migraines can cause spasm of the labyrinthine artery, which can predispose patients to recurrent episodes of BPPV. Another related factor seems to be aging, as the condition is more common in the elderly than in younger populations.

BPPV is common, accounting for about 20% of all dizziness in general and 50% in older patients.

SYMPTOMS OF BPPV?

Symptoms include spinning, lightheadedness, imbalance, and at times nausea. While symptoms may vary among persons, they are almost always caused by a change in position of the head with respect to gravity. An intermittent pattern is common where symptoms may be present for a few days/weeks, then stop, and return again.

WHAT CAUSES BPPV?

In about half of all cases, BPPV is called “idiopathic,” which means it occurs for no known reason. The utricle may have been damaged by viral infection, stroke, head injury, disorders of the inner ear, or may be due to deterioration from age. There is also an association with migraine (Ishiyama et al, 2000).

HOW IS THE DIAGNOSIS OF BPPV MADE?

A specialist may diagnose based on history of symptoms, findings on physical examination, and the results of vestibular and auditory tests. Often, the diagnosis can be made with history and a physical examination called the Dix Hallpike.

Patients who have BPPV will have indicative eye movements, called nystagmus, that correspond with the abnormal nerve stimulation in the vestibular system. When you get an evaluation for dizziness, there are many tests that may be ordered by your physician. However, there is one test in particular that is used to determine the presence of BPPV. This test is called Epley’s maneuver, for Dr. John Epley who first developed and described the test.

HOW IS BPPV TREATED?

Most often treatment includes a canalith repositioning maneuver. This maneuver consists of a series of head movements which help the debris move to another area of the inner ear where they will not cause symptoms. The debris is thought to dissolve naturally as well as become actively reabsorbed in this new position.

 TREATMENT OF BPPV: The Epley Maneuver

 

The Epley Maneuver is very effective, with roughly an 80% cure rate, according to a study by Herdman and others (1993). The maneuver is intended to move debris out of the semi-circular canals to a less sensitive location. The maneuver takes about 15 minutes to complete and is illustrated here. We may use vibration in an effort to dislodge any debris which may be adhered to the semi-circular canal wall and/or sensory cell.

The recurrence rate for BPPV after these maneuvers is about 30 percent at one year, and in some instances multiple treatments may be necessary.

After this maneuver, prepare to follow the instructions below, which are aimed at reducing the chance that debris might fall back into the sensitive part of the ear.

 

Here is a video for the Epley Manuever for Right Ear Posterior Canal BPPV,from Dr. Christopher Chang.

 


INSTRUCTIONS FOR PATIENTS AFTER OFFICE TREATMENTS

1. Wait for 10 minutes after the maneuver before leaving the office. This is to avoid “quick spins,” or brief bursts of vertigo as debris repositions itself immediately after the maneuver. As you are driving, be careful checking your blind-spots, quick head movements, as well as getting into and out of your car.

2. For at least 1 week, avoid quick head movements, up and down head positions, bending or lying down. Do not place head in positions you know provoke your symptoms. Try to stay as upright and vertical as possible. This is especially important while washing hair and face, brushing teeth, bending over to pick things up or tying shoes, and during activities requiring tilting of the head above or below eye level (reading, cleaning, reaching.) Try to avoid looking down on the stairs, the beauty parlor and dentist’s office. Do not partake in exercise requiring head movement or horizontal positioning of the body (i.e. “sit-ups,” and freestyle “crawl” swimming, however breast stroke is OK). If eyedrops are required, put them in without tilting the head back.

3. For at least the next three nights, 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 lots of pillows/towels. Be careful lying on your back or with your head turned towards the “bad” side.

4. One week after treatment, put yourself in the position that usually makes you dizzy. Position yourself cautiously and under conditions in which you cannot fall or hurt yourself. Let your doctor know how you did.

**If you feel dizziness, return back to your upright position and fix your eyes on an object. If a stable object is near, hold onto it. Take it easy thereafter and follow instructions #2 and #3 above. If your symptoms continue, worsen, or are markedly different make an appointment as soon as possible.

 

Source:  Hain, T.   “Benign Paroxysmal Positional Vertigo.” Dizziness and Balance                             –www.dizziness-and-balance.com

 

 

 

 

 

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