BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV)
What is benign paroxysmal positional vertigo BPPV?
Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness and also one of the easiest to diagnose and treat. It is characterized by true vertigo and geotropic rotary nystagmus (rhythmic movement of the eyes) that occurs for a few seconds after specific head movements, such as rolling over in bed, bending over, or looking up. The vertigo usually lasts no more than a minute. Both the vertigo and nystagmus tend to be less severe when the movement is repeated. Patients most often experience BPPV when lying down, which distinguishes BPPV from orthostatic hypotension. In addition, BPPV may be recurrent.
BPPV is not associated with any particular pattern of hearing loss.
What is the pathophysiology of BPPV?
BPPV is most likely caused by dislodged otoconia (calcium particles) shed from the utricular macula (a part of the ear which responds to linear motion). These otoconia migrate to the posterior semi-circular canal (a part of the ear that responds to rotational motion). These loose otoconia stimulate the nerve endings in the balance canals and send a message to your brain that you are moving in a direction you really are not. When the otoconia particles have dislodged, they may settle in sensory areas of the ear canal, or they may continue to “free float” within the canal. In either case, the presence of the otoconia sends misinformation about your position and head movement, causing vertigo. Whiplash injury, falls, a severe cold, or even high-impact exercises may accelerate this process. Individuals with prolonged periods of inactivity, such as those who are confined to a bed, may also develop BPPV.
How is BPPV diagnosed?
BPPV is diagnosed after a physician has evaluated a patient’s clinical history. Typically, patients with BPPV complain of vertigo when they lean forward, sit up, or roll over in bed. The diagnosis is confirmed by a positive response on the Dix-Hallpike test, which will be discussed in the next section.
What is the Dix-Hallpike test?
The Dix-Hallpike test is used to diagnose BPPV. During the test, a patient sits on the examination table, with his or her head turned either to the right or left. The patient is then moved rapidly from a sitting position to a supine position with the head hanging off of the back of the examining table. The patient is instructed to keep his/her eyes open so that the examiner can observe the patient’s eye movement during the entire procedure. If BPPV is present, vertigo will begin after 5 to 10 seconds and usually will last 30 seconds to a minute. Rotary nystagmus will occur, and the patient will complain of dizziness. After the nystagmus and the vertigo subside, the patient is returned to the sitting position. The opposite side is then tested in a similar fashion. The offending ear is the one that is toward the ground when BPPV occurs during the Dix-Hallpike maneuver.
How is BPPV treated?
BPPV is treated by the Canalith Repositioning Procedure (CRP), also known as the Epley maneuver. During CRP, the patient is moved through several positions to slowly move the otoconia particles from the posterior semicircular canal back into the utricle. The entire CRP maneuver takes approximately five minutes. The patient is instructed not to bend down or lie flat for 48 hours after the procedure. Two weeks after the CRP, the Dix-Hallpike test is repeated. Most patients are not symptomatic, and the Dix-Hallpike maneuver elicits neither nystagmus nor vertigo. If the patient does experience vertigo and nystagmus, then the CRP is repeated.
CRP offers the most effective and tolerable treatment for BPPV. Long-term follow-up is not required, and there is no need for medication. CRP presents minimal stress to the patient, other than post-procedure inconvenience.
How effective is the CRP technique?
After the first CRP procedure, more than 80 percent of patients no longer experience vertigo or nystagmus. Patients who do not respond to the first CRP and undergo a second or third procedure, have an overall success rate of greater than 90 percent.
Patients who fail after three attempts with CRP undergo further diagnostic evaluation to determine the cause of their vertigo.
If you are scheduled to have the CRP procedure treatment for BPPV, please click here for instructions.
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