BPPV Cause, Diagnosis and Treatment for People in Joliet, New Lenox and Morris, IL
In Benign Paroxysmal Positional Vertigo (BPPV), dizziness and vertigo are generally thought to be due to debris that has collected within a part of the inner ear. This debris, often responsible for paroxysmal positional vertigo, 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.” 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 disorders 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 universally accepted (see Zucca, 1998, and Buckingham, 1999).
BPPV is a common cause of dizziness and vertigo. About 20% of all dizziness cases are due to BPPV, a specific type of paroxysmal positional vertigo. While BPPV can occur in children (Uneri and Turkdogan, 2003), the older you are, the more likely it is that your dizziness is due to BPPV. About 50% of all dizziness in older people is related to benign paroxysmal positional vertigo. In a recent study, 9% of a group of urban-dwelling elders were found to have undiagnosed BPPV (Oghalai et al., 2000).
The symptoms of BPPV include dizziness or vertigo, lightheadedness, imbalance, and nausea. Activities that bring on symptoms vary among individuals, but symptoms of paroxysmal positional vertigo are almost always precipitated by a change in head position 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 tipping their heads back to look up, sometimes BPPV is called “top shelf vertigo.” Women with BPPV may find that shampoo bowls in beauty parlors bring on symptoms. An intermittent pattern is common — BPPV may be present for a few weeks, then stop, and then recur.
What causes BPPV?
The most common cause of benign paroxysmal positional vertigo in people under age 50 is head injury. There is also an association between BPPV and 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,” meaning it occurs for no known reason. Viruses affecting the ear, such as those causing vestibular neuritis, minor strokes like anterior inferior cerebellar artery (AICA) syndrome, and Meniere’s disease, are significant but less common causes. Occasionally, BPPV follows surgery, where the cause is thought to be prolonged supine positioning or ear trauma during the procedure (Atacan et al., 2001). BPPV is also common in persons treated with ototoxic medications such as gentamicin (Black et al., 2004). Other causes of positional vertigo symptoms are discussed here.
How is the diagnosis of BPPV made?
Your physician can diagnose benign paroxysmal positional vertigo based on your history, physical examination, and vestibular or auditory tests. Often, the diagnosis of BPPV can be made with history and physical examination alone. The key finding is that vertigo or dizziness is triggered by lying down or rolling over in bed. Most other conditions that cause positional dizziness worsen on standing rather than lying down (e.g., orthostatic hypotension).
Some rare conditions have symptoms that resemble BPPV. Patients with certain types of central vertigo, such as spinocerebellar ataxias, may have “bed spins” and prefer to sleep propped up in bed (Jen et al., 1998). These can generally be detected by a careful neurological exam and often have a family history of similar symptoms.
Electronystagmography (ENG) testing may be needed to identify the characteristic nystagmus (eye movement) induced by the Dix-Hallpike test. It has been claimed that BPPV accompanied by unilateral lateral canal paralysis may suggest a vascular cause (Kim et al., 1999). For accurate diagnosis of paroxysmal positional vertigo, ENG testing must include vertical eye movement measurement. MRI scans are performed if stroke or brain tumor is suspected. A rotatory chair test may be used for complex diagnostic cases. Although uncommon, about 5% of patients have BPPV in both ears (bilateral BPPV).
How is BPPV treated?
Wait It Out
BPPV is often described as “self-limiting” because vertigo symptoms frequently subside or disappear within two months of onset (Imai et al., 2005). Benign paroxysmal positional vertigo is not life-threatening, so one may choose to wait it out.
No Active Treatment (Wait/See)
If you decide to wait, daily adjustments may help you manage BPPV symptoms. Use two or more pillows at night and avoid sleeping on the “bad” side. When getting up, move slowly and sit briefly before standing. Avoid bending or extending your head, such as when reaching into cabinets. Be cautious at the dentist’s office, beauty salon, and during sports or activities involving lying flat.
Because BPPV symptoms can wax and wane, motion-sickness medications may help control nausea but are otherwise not very effective. Since paroxysmal positional vertigo can last longer than two months, active treatment is usually preferred over simply waiting.
Office Treatment of BPPV: The Epley and Semont Maneuvers
There are two common office-based treatments for BPPV performed by physical therapists: the Epley and Semont maneuvers. Both are highly effective, achieving about an 80% cure rate (Herdman et al., 1993). If your doctor is unfamiliar with these BPPV treatments, you can find knowledgeable clinicians via the Vestibular Disorders Association (VEDA).
Both maneuvers aim to move debris or “ear rocks” out of the sensitive part of the ear canal to a less sensitive area, resolving paroxysmal positional vertigo. Each maneuver takes about 15 minutes. The Semont (or “liberatory”) maneuver involves rapid side-to-side movement and achieves roughly 90% effectiveness after four sessions. The Epley maneuver, also called the particle repositioning or canalith repositioning procedure, uses four sequential head positions. The recurrence rate for BPPV after these maneuvers is about 30% at one year.
Some practitioners suggest modifications — for example, omitting position D — but mathematical modeling of BPPV shows this step is crucial (Squires et al., 2004). If neurological symptoms such as weakness or visual changes occur during the maneuvers, stop immediately and consult a physician, as these could indicate vertebral artery compression (Sakaguchi et al., 2003).
Instructions For Patients After Office Treatments (Epley or Semont Maneuvers)
After treatment for BPPV, wait 10 minutes before leaving to avoid sudden vertigo (“quick spins”).
Sleep semi-recumbent for two nights at a 45° angle.
During the day, keep your head vertical and avoid positions that may bring paroxysmal positional vertigo back.
Avoid head extensions at salons, dental offices, or during exercise.
Do not perform Brandt-Daroff exercises immediately unless instructed.
At one week, cautiously test the provoking position and report results to your doctor.
What is the proof that the Epley/Semont Maneuvers work?
More than 394 patients have been reported in controlled studies. The median response in treated patients was 81%, compared to 37.% in placebo or untreated subjects.
What if the maneuvers don't work?
These maneuvers are effective for most BPPV patients. If not, your doctor may recommend Brandt-Daroff or habituation exercises. When all non-surgical treatments fail, posterior canal plugging surgery may be considered.
BPPV often recurs: about one-third of patients experience recurrence within a year, and about half within five years (Hain et al., 2000; Nunez et al., 2000; Sakaida et al., 2003). Re-treatment with the Epley or Semont maneuvers is typically successful. In some cases, positional vertigo resolves but imbalance persists, and vestibular rehabilitation may help restore stability.
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 may take longer than the other maneuvers — the response rate at one week is about 25% (Radke et al., 1999). 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 42 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.
When performing the Brandt-Daroff maneuver, caution is advised should neurological symptoms (i.e. weakness, numbness, visual changes other than vertigo) occur. Occasionally such symptoms are caused by compression of the vertebral arteries (Sakaguchi et al., 2003). In this situation we advise not proceeding with the exercises and consulting ones physician.
Home Epley Maneuver
The Epley and/or Semont maneuvers as described above can be done at home (Furman and Hain, 2004). We may recommend the home-Epley to our patients who have a clear diagnosis. This procedure seems to be even more effective than the in-office procedure, perhaps because it is repeated every night for a week.
There are, however, several possible problems that may arise. If the diagnosis of BPPV has not been confirmed, one may be attempting to treat another condition (such as a brain tumor or stroke) with positional exercises — this is unlikely to be successful and may delay proper treatment. A second problem is that the home-Epley requires knowledge of the “bad” side. Sometimes this can be tricky to establish. Complications such as conversion to another canal (see below) can occur during the Epley maneuver, which are better handled in a doctor’s office than at home. Finally, occasionally during the Epley maneuver neurological symptoms are provoked due to compression of the vertebral arteries. In our opinion, it is safer to have the first Epley performed in a doctor’s office where appropriate action can be taken in this eventuality.
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 85-90% of individuals who have had no response to any other treatment (Shaia et al., 2006). Only about 1 percent of our BPPV patients eventually have this procedure done. Surgery should not be considered until all three maneuvers/exercises (Office Epley, Office Semont, Home Epley) have been attempted and failed.
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 conventional 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. Similarly, transtympanic gentamicin treatment seems generally inappropriate. Labyrinthectomy and sacculotomy are also both generally inappropriate because of reduction or loss of hearing expected with these procedures.
Atypical BPPV
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. It is also possible that some are due to other conditions such as brainstem or cerebellar damage, but clinical experience suggests that this is very rare.
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 3-12 percent of cases (Korres et al., 2002; Hornibrook 2004). Many 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 sagittal 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). We have encountered a few patients who ONLY have nystagmus in the head-hanging position. 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, when debris is falling backwards towards the ampulla, the torsional nystagmus should beat away from the bad ear. During the up phase of the Dix-Hallpike, when debris is moving towards the vestibule, the torsional nystagmus should beat towards the bad ear.
Lateral Canal BPPV
Is the most common atypical BPPV variant, accounting for about 3-12 percent of cases (Korres et al., 2002; Hornibrook 2004). Many 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.
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. Gradually a literature is developing about these situations (Bertholon et al., 2005).
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 its 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.
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