Benign paroxysmal positional vertigo
Encyclopedia
Benign paroxysmal positional vertigo (BPPV) is a disorder caused by problems in the inner ear
. Its symptoms are repeated episodes of positional vertigo
, that is, of a spinning sensation caused by changes in the position of the head.
, a distinct process some people confuse with dizziness, accounts for about 6 million clinic visits in the U.S. every year, and 17–42% of these patients eventually are diagnosed with BPPV. Other causes of vertigo include:
Patients do not experience other neurological deficits such as numbness or weakness
, and if these symptoms are present, a more serious etiology such as posterior circulation stroke
, must be considered.
lie collections of calcium crystals known as otoconia or otoliths. In patients with BPPV, the otoconia are dislodged from their usual position within the utricle and they migrate over time into one of the semicircular canals (the posterior canal is most commonly affected due to its anatomical position). When the head is reoriented relative to gravity, the gravity-dependent movement of the heavier otoconial debris (colloquially "ear rocks") within the affected semicircular canal causes abnormal (pathological) fluid endolymph
displacement and a resultant sensation of vertigo
. This more common condition is known as canalithiasis.
In rare cases, the crystals themselves can adhere to a semicircular canal cupula
rendering it heavier than the surrounding endolymph. Upon reorientation of the head relative to gravity, the cupula is weighted down by the dense particles thereby inducing an immediate and maintained excitation of semicircular canal afferent nerve
s. This condition is termed cupulolithiasis.
There is evidence in the dental literature that malleting of an osteotome
during closed sinus floor elevation, otherwise known as osteotome sinus elevation or lift, transmits enough percussive and vibratory forces capable of detaching otoliths from their normal location and leading to the symptoms of BPPV.
It can be triggered by any action which stimulates the posterior semi-circular canal which may be:
BPPV may be made worse by any number of modifiers which may vary between individuals:
BPPV is one of the most common vestibular disorders in patients presenting with dizziness and migraine is implicated in idiopathic cases. Proposed mechanisms linking the two are genetic factors and vascular damage to the labyrinth.
The Dix-Hallpike test is a common test performed by examiners to determine whether the posterior semicircular canal
is involved. It involves a reorientation of the head to align the posterior semicircular canal (at its entrance to the ampulla
) with the direction of gravity. This test will reproduce vertigo and nystagmus characteristic of posterior canal BPPV.
The roll test can determine whether the horizontal semicircular canal
is involved. The roll test requires the patient to be in a supine position with his/her head in 20° of cervical flexion. Then the examiner quickly rotates the head 90° to the left side, and checks for vertigo and nystagmus
. This is followed by gently bringing the head back to the starting position. The examiner then quickly rotates the head 90° to the right side, and checks for vertigo and nystagmus. In this roll test, the patient may experience vertigo and nystagmus on both sides, but rotating towards the affected side will trigger a more intense vertigo. Similarly, when the head is rotated towards the affected side, the nystagmus will beat towards the ground and be more intense.
As mentioned above, both the Dix-Hallpike and roll test provoke the signs and symptoms in subjects suffering from archetypal BPPV. The signs and symptoms patients with BPPV experience are typically a short-lived vertigo, and observed nystagmus. In some patients, though rarely, the vertigo can persist for years. Assessment of BPPV is best done by a health professional skilled in management of dizziness disorders, commonly a physiotherapist, audiologist or other medical physician
.
The nystagmus associated with BPPV has several important characteristics which differentiate it from other types of nystagmus.
, and the liberatory or Semont maneuver. The CRP employs gravity to move the calcium
build-up that causes the condition. The particle repositioning maneuver can be performed during a clinic visit by health professionals or taught to patients to practice at home. In the Semont maneuver, patients themselves are able to achieve canalith repositioning. Both treatments, when performed by a health professional, appear to be equally effective. When practiced at home, the CRP is more effective than the Semont maneuver. The most effective repositioning treatment for posterior canal BPPV is the therapist-performed CRP combined with home practiced CRP.
The Epley maneuver (particle repositioning) does not address the actual presence of the particles (otoconia), rather it changes their location. The maneuver aims to move these particles from areas in the inner ear which cause symptoms, such as vertigo, and repositions them to where they do not cause these problems.
The Brandt-Daroff exercises may be prescribed by the clinician as a home treatment method usually in conjunction with particle repositioning maneuvers or in lieu of the particle repositioning maneuver. The exercise is a form of habituation exercise, designed to allow the patient to become accustom to the position which causes the vertigo
symptoms. The Brandt-Daroff exercises are performed in a similar fashion to the Semont maneuver; however, as the patient rolls onto the unaffected side, the head is rotated toward the affected side. The exercise is typically performed 3 times a day with 5-10 repetitions each time, until symptoms of vertigo have resolved for at least 2 days.
Medical treatment with anti-vertigo medications may be considered in acute, severe exacerbation of BPPV, but in most cases are not indicated. These primarily include drugs of the anti-histamine and anti-cholinergic class, such as meclozine
and scopolamine
respectively. The medical management of vestibular syndromes has become increasingly popular over the last decade, and numerous novel drug therapies (including existing drugs with new indications), have emerged for the treatment of vertigo/dizziness syndromes. These drugs vary considerably in their mechanisms of action, with many of them being receptor or ion channel-specific. Among them, include betahistine or dexamethasone/gentamicin for the treatment of Ménière's disease
, carbamazepine/oxcarbazepine for the treatment of paroxysmal dysarthria
and ataxia
in multiple sclerosis
, metoprolol/topiramate or valproic acid/tricyclic antidepressant for the treatment of vestibular migraine, and 4-aminopyridine for the treatment of episodic ataxia type 2 and downbeat and upbeat nystagmus. These drug therapies offer symptomatic treatment, and do not affect the disease process or resolution rate. Medications may be used to suppress symptoms during the positioning manoeuvres if the patient's symptoms are severe and intolerable. More dose-specific studies are required however, in order to determine the most effective drug(s) for both acute symptom relief and long term remission of the condition. For a complete list of these novel therapies and their associated target symptoms, follow the link below to the Informahealthcare website.
Surgical treatments, such as a semi-circular canal occlusion, do exist for BPPV but carry the same risk as any neurosurgical procedure. Surgery is reserved as a last resort option for severe and persistent cases which fail vestibular rehabilitation (including particle repositioning and habituation therapy).
Devices such as a head over heels "rotational chair" are available at some tertiary care centers Home devices, like the DizzyFIX
, are also available for the treatment of BPPV and vertigo.
The Semont maneuver has a cure rate of 90.3%. It is performed as follows:
1. The patient is seated on a treatment table with their legs hanging off the side of the table. The therapist then turns the patient’s head towards the unaffected side 45 degrees.
2. The therapist then quickly tilts the patient so they are lying on the affected side. The head position is maintained, so their head is turned up 45 degrees. This position is maintained for 3 minutes. The purpose is to allow the debris to move to the apex of the ear canal.
3. The patient is then quickly moved so they are lying on the unaffected side with their head in the same position (now facing downwards 45 degrees). This position is also held for 3 minutes. The purpose of this position is to allow the debris to move toward the exit of the ear canal.
4. Finally, the patient is slowly brought back to an upright seated position. The debris should than fall into the utricle of the canal and their symptoms of vertigo should decrease or end completely. Some patients will only need one treatment, but others may need multiple treatments depending on the severity of their BPPV.
Great summary and picturgraphs of treatment positions.
Inner ear
The inner ear is the innermost part of the vertebrate ear. In mammals, it consists of the bony labyrinth, a hollow cavity in the temporal bone of the skull with a system of passages comprising two main functional parts:...
. Its symptoms are repeated episodes of positional vertigo
Vertigo (medical)
Vertigo is a type of dizziness, where there is a feeling of motion when one is stationary. The symptoms are due to a dysfunction of the vestibular system in the inner ear...
, that is, of a spinning sensation caused by changes in the position of the head.
Classification
VertigoVertigo (medical)
Vertigo is a type of dizziness, where there is a feeling of motion when one is stationary. The symptoms are due to a dysfunction of the vestibular system in the inner ear...
, a distinct process some people confuse with dizziness, accounts for about 6 million clinic visits in the U.S. every year, and 17–42% of these patients eventually are diagnosed with BPPV. Other causes of vertigo include:
- Motion sicknessMotion sicknessMotion sickness or kinetosis, also known as travel sickness, is a condition in which a disagreement exists between visually perceived movement and the vestibular system's sense of movement...
/ Motion Intolerance: a disjunction between visual stimulation, vestibular stimulation, and/or proprioceptionProprioceptionProprioception , from Latin proprius, meaning "one's own" and perception, is the sense of the relative position of neighbouring parts of the body and strength of effort being employed in movement... - Visual exposure to nearby moving objects (examples of optokineticOptokinetic reflexThe optokinetic reflex allows the eye to follow objects in motion when the head remains stationary . The reflex develops at about 6 months of age.-See also:...
stimuli: passing cars, falling snow) - Other diseases: (labyrinthitisLabyrinthitisLabyrinthitis is an inflammation of the inner ear, and a form of unilateral vestibular dysfunction. It derives its name from the labyrinths that house the vestibular system . Labyrinthitis can cause balance disorders....
, Ménière's diseaseMénière's diseaseMénière's disease is a disorder of the inner ear that can affect hearing and balance to a varying degree. It is characterized by episodes of vertigo and tinnitus and progressive hearing loss, usually in one ear. It is named after the French physician Prosper Ménière, who, in an article published...
, migraineMigraineMigraine is a chronic neurological disorder characterized by moderate to severe headaches, and nausea...
. etc.)
Signs and symptoms
- Symptoms
- Vertigo: Spinning dizziness, which must have a rotational component.
- Short duration (Paroxysmal): Lasts only seconds to minutes
- Positional in onset: Can only be induced by a change in position.
- NauseaNauseaNausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...
is often associated - Visual disturbance: It may be difficult to read or see during an attack due to the associated nystagmus.
- Pre-Syncope (feeling faint) or Syncope (fainting) is unusual.
- Emesis (Vomiting) is uncommon but possible.
- Signs
- Rotatory (torsional) nystagmus, where the top of the eye rotates towards the affected ear in a beating or twitching fashion, which has a latency and can be fatigued (if you repeatedly continue placing yourself in the position to cause vertigo the symptoms should lessen each time).
- Nystagmus should only last for 30 seconds to a minute.
Patients do not experience other neurological deficits such as numbness or weakness
Weakness
Weakness is a symptom represented, medically, by a number of different conditions, including: lack of muscle strength, malaise, dizziness, or fatigue. The causes are many and can be divided into conditions that have true or perceived muscle weakness. True muscle weakness is a primary symptom of a...
, and if these symptoms are present, a more serious etiology such as posterior circulation stroke
Stroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
, must be considered.
Cause
Within the labyrinth of the inner earEar
The ear is the organ that detects sound. It not only receives sound, but also aids in balance and body position. The ear is part of the auditory system....
lie collections of calcium crystals known as otoconia or otoliths. In patients with BPPV, the otoconia are dislodged from their usual position within the utricle and they migrate over time into one of the semicircular canals (the posterior canal is most commonly affected due to its anatomical position). When the head is reoriented relative to gravity, the gravity-dependent movement of the heavier otoconial debris (colloquially "ear rocks") within the affected semicircular canal causes abnormal (pathological) fluid endolymph
Endolymph
Endolymph is the fluid contained in the membranous labyrinth of the inner ear. It is also called Scarpa's fluid, after Antonio Scarpa.-Composition:...
displacement and a resultant sensation of vertigo
Vertigo (medical)
Vertigo is a type of dizziness, where there is a feeling of motion when one is stationary. The symptoms are due to a dysfunction of the vestibular system in the inner ear...
. This more common condition is known as canalithiasis.
In rare cases, the crystals themselves can adhere to a semicircular canal cupula
Cupula
The cupula is a structure in the vestibular system, providing proprioception.The cupula is located within the ampullae of each of the three semicircular canals...
rendering it heavier than the surrounding endolymph. Upon reorientation of the head relative to gravity, the cupula is weighted down by the dense particles thereby inducing an immediate and maintained excitation of semicircular canal afferent nerve
Afferent nerve
In the nervous system, afferent neurons , carry nerve impulses from receptors or sense organs towards the central nervous system. This term can also be used to describe relative connections between structures. Afferent neurons communicate with specialized interneurons...
s. This condition is termed cupulolithiasis.
There is evidence in the dental literature that malleting of an osteotome
Osteotome
An osteotome is an instrument used for cutting or preparing bone.The instrument was invented by Bernhard Heine, a German physician in Würzburg, in 1830. Heine's invention was used as a bone saw, especially for opening the skull. It was a kind of chain saw moved by turning a winder.Today osteotomes...
during closed sinus floor elevation, otherwise known as osteotome sinus elevation or lift, transmits enough percussive and vibratory forces capable of detaching otoliths from their normal location and leading to the symptoms of BPPV.
It can be triggered by any action which stimulates the posterior semi-circular canal which may be:
- Tilting the head
- Rolling over in bed
- Looking up or under
- Sudden head motion
- Post head injury
BPPV may be made worse by any number of modifiers which may vary between individuals:
- Changes in barometric pressure - patients often feel symptoms approximately two days before rain or snow
- Lack of sleep (required amount of sleep may vary widely)
- Stress
BPPV is one of the most common vestibular disorders in patients presenting with dizziness and migraine is implicated in idiopathic cases. Proposed mechanisms linking the two are genetic factors and vascular damage to the labyrinth.
Diagnosis
The condition is diagnosed by taking a patient history, and by performing the Dix-Hallpike maneuver and/or the roll test. Patients with BPPV will report a history of vertigo as a result of fast head movements. Many patients are also capable of describing the exact head movements that provokes their vertigo.The Dix-Hallpike test is a common test performed by examiners to determine whether the posterior semicircular canal
Posterior semicircular canal
The posterior semicircular canal is a part of the vestibular system and detects rotations of the head in the sagittal plane.-Structure:It is directed superiorly, as per its nomenclature, and posteriorly, nearly parallel to the posterior surface of the petrous bone...
is involved. It involves a reorientation of the head to align the posterior semicircular canal (at its entrance to the ampulla
Osseous ampullae
The bony semicircular canals are three in number, superior, posterior, and lateral, and are situated above and behind the vestibule. They are unequal in length, compressed from side to side, and each describes the greater part of a circle. Each measures about 0.8 mm...
) with the direction of gravity. This test will reproduce vertigo and nystagmus characteristic of posterior canal BPPV.
The roll test can determine whether the horizontal semicircular canal
Horizontal semicircular canal
The lateral or horizontal canal is the shortest of the three canals. Movement of fluid within this canal corresponds to rotation of the head around a vertical axis The lateral or horizontal canal (external semicircular canal) is the shortest of the three canals. Movement of fluid within this canal...
is involved. The roll test requires the patient to be in a supine position with his/her head in 20° of cervical flexion. Then the examiner quickly rotates the head 90° to the left side, and checks for vertigo and nystagmus
Nystagmus
Nystagmus is a condition of involuntary eye movement, acquired in infancy or later in life, that may result in reduced or limited vision.There are two key forms of Nystagmus: pathological and physiological, with variations within each type. Nystagmus may be caused by congenital disorders,...
. This is followed by gently bringing the head back to the starting position. The examiner then quickly rotates the head 90° to the right side, and checks for vertigo and nystagmus. In this roll test, the patient may experience vertigo and nystagmus on both sides, but rotating towards the affected side will trigger a more intense vertigo. Similarly, when the head is rotated towards the affected side, the nystagmus will beat towards the ground and be more intense.
As mentioned above, both the Dix-Hallpike and roll test provoke the signs and symptoms in subjects suffering from archetypal BPPV. The signs and symptoms patients with BPPV experience are typically a short-lived vertigo, and observed nystagmus. In some patients, though rarely, the vertigo can persist for years. Assessment of BPPV is best done by a health professional skilled in management of dizziness disorders, commonly a physiotherapist, audiologist or other medical physician
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
.
The nystagmus associated with BPPV has several important characteristics which differentiate it from other types of nystagmus.
- Positional: the nystagmus occurs only in certain positions
- Latency of onset: there is a 5-10 second delay prior to onset of nystagmus
- Nystagmus lasts for 5–120 seconds
- Visual fixation suppresses nystagmus due to BPPV
- Rotatory/Torsional component is present or (in the case of lateral canal involvement) the nystagmus beats in either a geotropic (towards the ground) or ageotropic (away from the ground) fashion
- Repeated stimulation, including via Dix-Hallpike maneuvers, cause the nystagmus to fatigue or disappear temporarily.
Treatment
Two treatments have been found effective for relieving symptoms of posterior canal BPPV: the canalith repositioning procedure (CRP) or Epley maneuverEpley maneuver
The Epley maneuver is a maneuver used to treat benign paroxysmal positional vertigo . It is often performed by a doctor, chiropractor, or a physical therapist, after confirmation of a diagnosis of BPPV using the Dix-Hallpike . This maneuver was developed by Dr. John Epley and first described in 1980...
, and the liberatory or Semont maneuver. The CRP employs gravity to move the calcium
Calcium
Calcium is the chemical element with the symbol Ca and atomic number 20. It has an atomic mass of 40.078 amu. Calcium is a soft gray alkaline earth metal, and is the fifth-most-abundant element by mass in the Earth's crust...
build-up that causes the condition. The particle repositioning maneuver can be performed during a clinic visit by health professionals or taught to patients to practice at home. In the Semont maneuver, patients themselves are able to achieve canalith repositioning. Both treatments, when performed by a health professional, appear to be equally effective. When practiced at home, the CRP is more effective than the Semont maneuver. The most effective repositioning treatment for posterior canal BPPV is the therapist-performed CRP combined with home practiced CRP.
The Epley maneuver (particle repositioning) does not address the actual presence of the particles (otoconia), rather it changes their location. The maneuver aims to move these particles from areas in the inner ear which cause symptoms, such as vertigo, and repositions them to where they do not cause these problems.
The Brandt-Daroff exercises may be prescribed by the clinician as a home treatment method usually in conjunction with particle repositioning maneuvers or in lieu of the particle repositioning maneuver. The exercise is a form of habituation exercise, designed to allow the patient to become accustom to the position which causes the vertigo
Vertigo
Vertigo is a form of dizziness.Vertigo may also refer to:* Vertigo , a 1958 film by Alfred Hitchcock**Vertigo , its soundtrack** Vertigo effect, or Dolly zoom, a special effect in film, named after the movie...
symptoms. The Brandt-Daroff exercises are performed in a similar fashion to the Semont maneuver; however, as the patient rolls onto the unaffected side, the head is rotated toward the affected side. The exercise is typically performed 3 times a day with 5-10 repetitions each time, until symptoms of vertigo have resolved for at least 2 days.
Medical treatment with anti-vertigo medications may be considered in acute, severe exacerbation of BPPV, but in most cases are not indicated. These primarily include drugs of the anti-histamine and anti-cholinergic class, such as meclozine
Meclozine
Meclozine is an antihistamine considered to be an antiemetic. It is sold under the brand names Bonine, Bonamine, Antivert, Postafen, Sea Legs, and Dramamine . Emesafene is a combination of meclozine and pyridoxine...
and scopolamine
Scopolamine
Scopolamine, also known as levo-duboisine, and hyoscine, is a tropane alkaloid drug with muscarinic antagonist effects. It is among the secondary metabolites of plants from Solanaceae family of plants, such as henbane, jimson weed and Angel's Trumpets , and corkwood...
respectively. The medical management of vestibular syndromes has become increasingly popular over the last decade, and numerous novel drug therapies (including existing drugs with new indications), have emerged for the treatment of vertigo/dizziness syndromes. These drugs vary considerably in their mechanisms of action, with many of them being receptor or ion channel-specific. Among them, include betahistine or dexamethasone/gentamicin for the treatment of Ménière's disease
Ménière's disease
Ménière's disease is a disorder of the inner ear that can affect hearing and balance to a varying degree. It is characterized by episodes of vertigo and tinnitus and progressive hearing loss, usually in one ear. It is named after the French physician Prosper Ménière, who, in an article published...
, carbamazepine/oxcarbazepine for the treatment of paroxysmal dysarthria
Dysarthria
Dysarthria is a motor speech disorder resulting from neurological injury of the motor component of the motor-speech system and is characterized by poor articulation of phonemes...
and ataxia
Ataxia
Ataxia is a neurological sign and symptom that consists of gross lack of coordination of muscle movements. Ataxia is a non-specific clinical manifestation implying dysfunction of the parts of the nervous system that coordinate movement, such as the cerebellum...
in multiple sclerosis
Multiple sclerosis
Multiple sclerosis is an inflammatory disease in which the fatty myelin sheaths around the axons of the brain and spinal cord are damaged, leading to demyelination and scarring as well as a broad spectrum of signs and symptoms...
, metoprolol/topiramate or valproic acid/tricyclic antidepressant for the treatment of vestibular migraine, and 4-aminopyridine for the treatment of episodic ataxia type 2 and downbeat and upbeat nystagmus. These drug therapies offer symptomatic treatment, and do not affect the disease process or resolution rate. Medications may be used to suppress symptoms during the positioning manoeuvres if the patient's symptoms are severe and intolerable. More dose-specific studies are required however, in order to determine the most effective drug(s) for both acute symptom relief and long term remission of the condition. For a complete list of these novel therapies and their associated target symptoms, follow the link below to the Informahealthcare website.
Surgical treatments, such as a semi-circular canal occlusion, do exist for BPPV but carry the same risk as any neurosurgical procedure. Surgery is reserved as a last resort option for severe and persistent cases which fail vestibular rehabilitation (including particle repositioning and habituation therapy).
Devices such as a head over heels "rotational chair" are available at some tertiary care centers Home devices, like the DizzyFIX
DizzyFIX
The DizzyFIX is an FDA cleared home medical device available to assist in the treatment of Benign Paroxysmal Positional Vertigo and its associated vertigo. The device itself is a head-worn representation of semi-circular canals. The device is filled with fluid and a particle representing the...
, are also available for the treatment of BPPV and vertigo.
The Semont maneuver has a cure rate of 90.3%. It is performed as follows:
1. The patient is seated on a treatment table with their legs hanging off the side of the table. The therapist then turns the patient’s head towards the unaffected side 45 degrees.
2. The therapist then quickly tilts the patient so they are lying on the affected side. The head position is maintained, so their head is turned up 45 degrees. This position is maintained for 3 minutes. The purpose is to allow the debris to move to the apex of the ear canal.
3. The patient is then quickly moved so they are lying on the unaffected side with their head in the same position (now facing downwards 45 degrees). This position is also held for 3 minutes. The purpose of this position is to allow the debris to move toward the exit of the ear canal.
4. Finally, the patient is slowly brought back to an upright seated position. The debris should than fall into the utricle of the canal and their symptoms of vertigo should decrease or end completely. Some patients will only need one treatment, but others may need multiple treatments depending on the severity of their BPPV.
External links
- VEDA Vestibular Disorder Association webpage concerning BPPV
- Benign Positional Vertigo. eMedicine at WebMD
- MayoClinic
- Diagnosis and management of benign paroxysmal positional vertigo by Lorne S. Parnes, Sumit K. Agrawal and Jason Atlas. Canadian Medical Association (CMAJ)
- Dizzytimes.com Online Community for Sufferers of Vertigo and Dizziness
- Medications. Medication for managing dizziness at Informahealthcare
Great summary and picturgraphs of treatment positions.
- http://www.med.upenn.edu/solomon/images/BPPV.pdf
- http://www.neurology.org/cgi/content/full/63/1/150/DC1?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=epley&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT