BPPV - Benign Paroxysmal Positional Vertigo
People experience dizziness in many different ways. Some people call their sense of dizziness or imbalance as a feeling of light-headedness. Others may describe it as feeling "drunk" or room-spinning. Even seizures and migraine headaches are sometimes reported as dizziness. As such, it is important that your doctor precisely determines what dizziness means for a given person and obtain information on when, how long, how often, and anything that may trigger a dizzy attack.
Figuring out what is causing a person's dizziness can be quite difficult because a doctor can't touch it, can't see it, can't feel it, can't smell it, etc. It is a sensation that is felt only by the patient and nobody else. As such, diagnosis requires a good history and potentially LOTS of testing.
Mainly there are 4 classes of dizziness:
- inner ear problems (ie, BPPV and Meniere's)
- medication side effects(hypertension and neuro/psych medications are the most common)
- brain/spine problems (ie, stroke, brain tumor, etc)
- heart/vessel problem (ie, cardiac rhythm problems, stenosis of the carotid artery, etc)
However, the MOST common cause of spinning dizziness is a condition called Benign Paroxysmal Positional Vertigo, also known as BPPV which accounts for about 20% of all dizziness. The key characteristics common to patients suffering from BPPV include:
- Triggered by position change, typically turning.
- Usually does not last more than a few minutes.
- May cause nausea and vomiting if vertigo severe enough.
- Period of relative normalcy in between dizzy attacks.
- No associated symptoms (no hearing changes, aural fullness, ear ringing)
BPPV occurs when particles which are normally anchored within the inner ear break free. Found within the semi-circular canals of the inner ear (see image below), such free-floating particle wreak havoc with a person's balance, especially given that the semi-circular canals are analogous to a gyroscope and help the brain determine where the head is located in space relative to gravity.
Normally, these particles are anchored within the inner ear and therefore their motion is limited. When a person turns the head, these anchored particles sway and than stop quickly. Such particle movement is how the inner ear tells the brain that a head turn just happened. The analogy would be a buoy in the ocean. When a wave motion occurs, the buoy moves with the wave motion, but quickly settles out once the wave passes.
However, when these particles become free-floating, they keep moving which essentially makes the inner ear tell the brain that the head is still turning even if it isn't. The end result is a spinning sensation which stops when the free-floating particles stop moving.
Viral infections, osteoporosis, head trauma, and vitamin D deficiency are risk factors for BPPV.
Once BPPV is suspected based on history, a maneuver can be performed called Dix-Hallpike to confirm BPPV as a diagnosis. Dix-Hallpike is performed in the following way (Watch Video):
Patient's head is rotated to one side by approximately 45 degrees. The clinician than helps the patient to lie down backwards quickly with the head held in approximately 20 degrees of extension. This extension may either be achieved by having the clinician supporting the head as it hangs off the table or by placing a pillow under their upper back. The patient's eyes are then observed for about 45 seconds as there is not uncommonly a characteristic 5–10 second delay prior to the onset of nystagmus. If repetitive eye jumping (nystagmus) occurs then the test is considered positive for possible BPPV.
Please note that a dizzy sensation WITHOUT nystagmus is NOT considered diagnostic for BPPV. Something else is causing the dizziness.
If nystagmus is seen, REPEAT 3 times the same maneuver to determine whether it fatigues. Fatigues is when the nystagmus progressively weakens when the test is repeated. If the response fatigues, the patient has confirmed BPPV. If the nystagmus does NOT fatigue, it suggests a problem other than the inner ear (ie, brain or spine).
Click here to go through a flowchart to determine what type of BPPV you have. Keep in mind that there are 6 different types of BPPV and depending on what type you have determines what maneuver to perform:
The treatment is to essentially move the free-floating particles into a location where its movement will not cause any problems. The treatment is analagous to physically moving a marble within a maze with the goal of depositing it into a hole, except the head is the maze and the free-floating particles is the marble.
The treatment for BPPV actually depends on where the free-floating particles are located within the semi-circular canals. The semi-circular canals are composed of 3 different canals: posterior, superior (or anterior), and lateral (or horizontal).
Click here to go through a flowchart to determine what type of BPPV you have in order to determine what type of exercise will work.
Posterior Canal BPPV
The posterior semi-circular canal is by far the most common location where BPPV occurs (~80% of all BPPV). With the Dix-Hallpike maneuver, the eyes appear to jump (nystagmus) towards the affected ear, which is the ear closest to the ground. The best treatment is a series of physical head and body maneuvers known as the Epley. Other variations of the Epley include the Semont as well as the Foster Half-Somersault. A video demonstrating the Epley can be watched here.
The Epley maneuver is performed as follows:
- The patient begins in an upright sitting posture, with the legs fully extended and the head rotated 45 degrees towards the affected side.
- The patient is then quickly and passively forced down backwards into a laying down position with the head held approximately in a 30 degree neck extension (Dix-Hallpike position) where the affected ear faces the ground.
- The clinician observes the patient's eyes for “primary stage” nystagmus. The patient remains in this position for approximately 30 seconds (takes about that long for the free-floating particles to settle into the new position).
- The patient's head is then turned 90 degrees to the opposite direction so that the unaffected ear faces the ground, all while maintaining the 30 degree neck extension. The patient remains in this position for approximately 30 seconds.
- Keeping the head and neck in a fixed position relative to the body, the individual rolls onto their shoulder, rotating the head another 90 degrees in the direction that they are facing. The patient is now looking downwards at a 45 degree angle. The eyes should be immediately observed by the clinician for “secondary stage” nystagmus and this secondary stage nystagmus should beat in the same direction as the primary stage nystagmus. The patient remains in this position for approximately 30 seconds.
- Finally, the patient is slowly brought up to an upright sitting posture, while maintaining the 45 degree rotation of the head. The patient holds sitting position for up to 30 seconds.
The entire procedure may be repeated two more times for a total of three times. During every step of this procedure the patient may experience some dizziness.
An alternative maneuver which may help posterior BPPV is called the Semont or liberatory maneuver demonstrated in the image below when the right ear is affected (Liberatory manoeuvre of Semont. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003:169:681-693):
- Patient is made to sit on the examination table with legs hanging over the edge and head turned 45 degrees horizontally towards the unaffected ear.
- While maintaining head rotation patient’s upper body is swiftly moved to side lying position on the affected side with head resting on examination table and nose pointed upwards. Position is maintained for 3 minutes or till vertigo and nystagmus subsides. This step moves the debris to the apex.
- Patient is rapidly moved through the sitting position (Position 1) to lying on the opposite or unaffected side (maintaining same head rotation) with nose pointed to the ground. Position is again maintained for 3 minutes or till the vertigo and nystagmus subsides. This maneuver moves the debris towards exit of the canal.
A final way to treat posterior canal BPPV is the Foster Half-Somersault (A comparison of two home exercises for benign positional vertigo: Half somersault versus Epley Maneuver. Audiol Neurotol Extra 2012;2:16-23). Watch video here. This maneuver is probably the most feasible to perform in situations where laying down is not possible (ie, at work or in a public place).
- While kneeling, the head is quickly tipped upward and back.
- The somersault position is assumed, with the chin tucked as far as possible toward the knee.
- The head is turned about 45° toward the right shoulder, to face the right elbow (if the right ear is affected).
- Maintaining the head at 45°, the head is raised to back/shoulder level.
- Maintaining the head at 45°, the head is raised to the fully upright position. Dark curved arrows show head movements. Lighter arrows near eyes show the direction one should be facing.
The whole idea with the Epley, Semont, or Foster is to move the free-floating particles into the utricle of the inner ear where it will no longer cause vertigo.
After the Epley, Semont, or Foster maneuver has been completed, it is important to follow post-treatment instructions to maximize the success of resolving the BPPV.
Sleep semi-recumbent for the next two nights (head at a 45 degree angle). This is most easily done by using a recliner chair or by using pillows arranged on a couch. During the day, try to keep your head vertical and stilll.
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 positions. This basically means to be cautious at the beauty parlor, dentist's office, and while undergoing minor surgery where the head is often bent back. Try to stay as upright as possible.
One week after treatment, no more restrictions are required and hopefully, the dizziness has completely resolved!
Lateral (or Hoizontal) Canal BPPV
The lateral semi-circular canal is a less common location where BPPV occurs (5-20% of all BPPV). Dix-Hallpike is usually positive revealing a horizontal nystagmus that changes direction according to the ear that is down. But, the "best' test is the supine roll test which starts with the body laid flat on the back, head inclined forward 30 degrees, and then turning the head to either side.
There is a series of physical head maneuvers known as the Gufoni which is used to treat lateral BPPV.
There are two "flavors" of lateral BPPV. For the geotrophic variant of lateral BPPV, one starts on the unaffected side (side of weaker nystagmus), and then proceeds to 45 deg nose down.
For the ageotrophic variant, one starts on the affected side (again side of weaker nystagmus), and proceeds to 45 deg nose up (Step C) which is demonstrated in the image below (Appiani et al, 2005):
Log-roll (Lempert) exercises may also work and can be performed at home. This exercise essentially begins by laying down with head turned to side of the bad ear. From this side position, the patient than turns head in 90 degree steps rolling onto the back as the turns happen. Each turn is held for 30 seconds. The maneuver is completed when the patient has rolled 360 degrees before sitting up (Image from Neurology). A video demonstrating the Lempert can be watched here.
Superior (or Anterior) Canal BPPV
The superior semi-circular canal is by far the least common location where BPPV occurs (about 2% of all BPPV). Dix-Hallpike maneuver will be positive, but the affected ear is opposite the side one would expect for a positive posterior BPPV. Treatment is a series of physical head and body maneuvers known as the Deep Head Hanging Maneuver. A video demonstrating the maneuver can be watched here.
The Deep Head Hanging maneuver is performed as follows (Gualtieri, et al. 2009). Essentially, the head is tilted back as close to 90 degrees as possible. After 30 seconds, the head is than bent forward as close to 45 degrees as possible and held for 30 seconds before sitting back up.
If you are suffering from BPPV, please contact our office for an appointment! Please be aware that we have a great deal of experience in the treatment of posterior BPPV but not as much with the other more rare forms of BPPV (anterior BPPV).
Please keep in mind that meclizine and dramamine which are often prescribed for ANY cause of dizziness, including BPPV, only treat the symptoms of dizziness without fixing the underying cause and in some cases, may even make dizziness worse (more info here)! Regarding the OTC patch below, this is NOT the same as the prescription motion sickness patch (scopolamine). Vitamin D3 appears to help decrease risk of BPPV (more info on the relationship between vitamin D levels and BPPV can be found here).
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