Benign Paroxysmal Positional Vertigo

About BPPV

Vertigo is the feeling that one’s surroundings are spinning, despite remaining stationary. There are a number of possible causes of vertigo, including benign paroxysmal positional vertigo – BPPV. Commonly BPPV produces a sensation of vertigo that is sudden and associated with certain movements of the head or changes in head position, such as turning to look in a particular direction. Hence, BPPV is also known as positional vertigo. Although BPPV is a hindrance, it generally does not result in serious harm to the sufferer. BPPV is more common in women than men and more frequently affects people aged above 40.

The vestibular system

BPPV is a condition which affects the vestibular system. The vestibular system is concerned with our sense of balance and is made up of a number of fluid-filled canals within the inner ear.

There are two subdivisions of the vestibular system;

• the semicircular canals, which are involved in sensing rotations of the head
• the otolith organs, which are involved in detecting linear head movements.

The otolith organs are implicated in BPPV. The otolith organs are the utricle and the saccule and are made up of tiny hair cells, which sense head movements and project into a layer of gel which has a number of small crystals embedded within it, known as otoliths.

Causes

In BPPV, the otoliths in the utricle and/or saccule become displaced, lodging in the semicircular canals. In many cases, the actual cause of the displacement is unable to be identified. Some potential causes of BPPV include middle ear surgery, trauma to the head/head injury, long periods of bed rest, Meniere’s disease and inner ear infections, such as labyrinthitis and vestibular neuritis. All of these possible causes may allow the otoliths to become displaced from their usual position.

Treatment

Whilst BPPV may resolve on its own accord, there are several treatment and management options which may help to improve symptoms and resolve the cause. Simple things which may help improve the symptoms of BPPV include avoiding lying on the affected side, sleeping with an extra pillow or two to elevate the position of the head and avoiding sudden head movements.

Manoeuvers

Canalith repositioning procedure – Epley manoeuver

The canalith repositioning procedure is used to move otoliths lodged in the posterior semicircular canals. This procedure involves a series of changes in head positions, each held for 30 seconds once the feeling of vertigo has subsided. This manoeuver aims to move the problematic otolith to an area where it will not produce symptoms. The steps involved in this technique are as follows:

1. The patient moves slowly from a sitting position to laying back (reclining), with their head turned to the problematic side at a 45 degree angle. The doctor will then slightly extend the patient’s head over the edge of the bed or table.
2. Once in this position, the patient will gradually turn their head away from the affected side by approximately 90 degrees
3. The patient will then roll to their side, slightly tilting their head to look down at the floor or ground
4. With a down-tilted head, the patient slowly returns to a sitting position. The head is slowly returned to the central position.

There are a couple of risks associated with the canalith repositioning procedure. These include injury to the neck or the back if poor technique is utilised and movement of the otolith into one of the other semicircular canals, which will continue to be symptomatic. There may also be nausea, vomiting and dizziness following the procedure. The procedure should be carried out with additional care in patients with neck injuries, some vascular (blood vessel) conditions and in people with detachment of the retina.

Semont’s Manoeuver

This technique was originally designed to change the position of particles in the cupula, but has also been found to be as effective as the canalith repositioning procedure for otoliths lodged in the posterior semicircular canals causing BPPV. This technique needs to be performed in a rapid manner and thus it may not be indicated for patients with limited neck mobility. The steps involved in Sermont’s manoeuver include:

1. The patient sits on the edge of the bed with their head turned 45 degrees to the unaffected side.
2. Place the patient in a side-lying position to the affected side, keeping the head in the position described above. Lie in this position for 1 minute.
3. Rapidly move the patient 180 degrees, so that they are lying on their unaffected side, keeping the head in the same original position.

Semont’s manoeuvre may be performed when the patient is wearing infrared goggles, which allow the doctor to monitor eye movements with the changing head position. As with the canalith repositioning procedure, there are a few risks which are associated with Semont’s manoeuver. The most common risk associated with Semont’s manoeuvre is displacement of the otolith from the posterior semicircular canal to another semicircular canal; which does not resolve the BPPV. This complication is most likely to occur if the original head position is not maintained when the patient is moved to the upright position.

Brandt-Daroff Exercises

Brandt-Daroff exercises are used in the treatment of BPPV and aim to unblock the semi-circular canals affected by otolith deposition. The following steps describe the Brandt-Daroff exercises:

1. Patient sits on the end of a bed or table and turns their head 45 degrees towards the left side
2. Keeping the head in this position, the patient needs to lie down quickly on their right hand side, so that the back of their head is resting on the bed or table. The patient should hold the position for about 30 seconds, or until any feelings of giddiness have subsided
3. The patient should then return to the sitting position and again wait around 30 seconds in this position, or until any giddiness or dizziness has resolved
4. The patient should then turn their head about 45 degrees towards their right side
5. With the head in this position, the patient should lie down quickly on their left hand side, ensuring that the back of their head is resting on the bed or on the table; as above, the patient should remain in this position for 30 seconds, or until any dizziness or giddiness has resolved
6. The patient should return themselves to the sitting position and wait for any giddiness to subside.

Brandt-Daroff exercises are useful if the positions cause the patient to experience dizziness or giddiness. If performed correctly, the patient’s symptoms may resolve within a few days of commencing an exercise program. They confer some benefit for patients who are not suitable for canalith repositioning techniques or Sermont’s manoeuver. Another advantage of the Brandt-Daroff exercises is that they are effective for any affected canal, not just the posterior semicircular canal. They may also be used to prevent recurrence of BPPV in patients who have achieved symptom control with one of the other aforementioned techniques.

Medication

Medications may have some value in the symptomatic treatment of BPPV. Drugs from the class of anti-emetics, which are designed to prevent nausea and vomiting, are sometimes used in the treatment of BPPV. These medications should be used with caution in patients with glaucoma and bladder obstruction. It is important to note that these medications have no effect on the feelings of vertigo experienced by individuals with BPPV, but instead reduce the symptoms of motion sickness which often comes on with the attacks of vertigo. The medications may cause side effects such as dry mouth and sedation. The medications are not indicated for long-term use, but are useful in the first few days of an exercise program, such as the Brandt-Daroff exercises, to reduce the nausea which may occur when initially commencing these exercises.

Surgery

Surgery is a last-resort treatment for BPPV and is reserved for people with disabling symptoms which do not respond to any other form of treatment. Surgery is rarely performed on patients with BPPV and surgical techniques only exist for the posterior semicircular canal. In the rare cases where surgery is performed, one option involves selectively dividing the nerve to the posterior semi-circular canal, so that the signals from the canal do not travel to the brain to produce symptoms. This procedure is not common, as it is a difficult technique and carries a risk of damage to other sections of the nerve, which carries information about hearing and balance to the brain. Hence, a complication which may arise following this procedure is permanent hearing loss.

Another possible surgical method involves mechanically blocking the posterior semicircular canal and is often very successful if utilised in well-selected patients. It is more commonly performed than the aforementioned operation. Transient hearing loss may be apparent in the weeks following the procedure, which is generally minor and will resolve over time. There is also a risk of permanent hearing loss from this procedure if the nerve carrying information from the ear to the brain is inadvertently damaged during the operation.

Points to remember

BPPV is a balance disorder which typically causes episodes of sudden and severe vertigo when the head is moved around. Common triggers include rolling over in bed, getting out of bed and lifting the head to look up. BPPV is caused by particles called canaliths within the balance organ of the inner ear. If you have questions about vertigo or BPPV contact your local doctor, who will arrange for you to see an Ear Nose Throat Specialist. We‘ll provide you with a straightforward, efficient and very effective treatment plan targeted to your condition.