Benign Paroxysmal Positional Vertigo
Dennis I. Bojrab, MD
Michigan Ear Institute
This is the most common cause of dizziness from an inner ear problem. It is termed benign paroxysmal positional vertigo for the following reason:
Benign: the condition almost always goes away with proper treatment
Paroxysmal: the condition may return causing vertigo without warning
Positional: it is brought on by specific type of head movement
Vertigo: the sensation is that of spinning that may be mild or violent
The dizziness is caused by dislodged calcium crystals (salt crystals) in the fluid of the inner ear. The calcium crystals move through the fluid of the inner ear during certain head movements of motion or dizziness (vertigo). The following are the most common reasons for dislodgment of calcium crystals in the inner ear:
1. Head trauma or whiplash injury
2. Aging of the inner ear
3. Other inner ear disorders – Meniere’s Disease, vestibular neuronitis, and labyrinthitis.
4. Idiopathic – medical science does not know the cause.
A patient with BPPV frequently will awake with vertigo. This occurs when rolling over in bed or sitting up, or looking up on a shelf. It may wake the person from sleep by turning over while asleep. Movement of the head will make the dizziness worse. The vertigo will usually stop after 30-60 seconds if the head is kept still. Symptoms occur while lying down in bed, rolling over, looking up on a shelf, downward to the side or when lying back to have one’s hair washed. Symptoms are generally not constant and improve throughout the day if the provoking position is not performed. Symptoms include attacks of vertigo, disequilibrium, unsteadiness, nausea, disorientation, and occasionally a “spacey” or detached feeling.
As a rule, BPPV patients do not experience hearing loss, ear fullness, or head noise. If these symptoms do exist, it is likely that a second inner ear problem exists.
BPPV is diagnosed on the basis of the clinical history and physical examination. It is possible that patient’s with this condition may have a negative physical examination performed by the doctor on the day of the appointment. It is even possible for the patient to have a normal electronystagmogram (ENG) if this test is performed on a day when the dizziness is not present.
Frequently the doctor will ask for the patient to return on a day when the dizziness is present in order to perform a detailed physical examination and hopefully confirm the diagnosis with the provocative Hallpike maneuver.
The goals of treatment are to eliminate or decrease the current symptoms. In the office if the doctor can provoke the dizziness, a specific type of nystagmus (uncontrollable eye movement) will occur causing a brief (15-45 seconds) bout of dizziness with the Hallpike maneuver. At that time a defined set of movements will be performed to the patient by the doctor to reposition the loose salt crystals (canaliths) into a “quiet” region of the inner ear. After the maneuver, a cervical neck collar will be applied with instructions for the next several days. This may include sleeping in bed on 3 pillows or in a reclining chair so as to keep the salt crystals in the proper area of the inner ear. This maneuver may need to be repeated at another office appointment if the dizziness does not clear or if it returns at another time in the future.
Another medical treatment for this condition involves the patient in a series of physical therapy maneuvers to alleviate dizziness. This is termed the Brandt -Daroff excercises. This involves a specific series of movements that the patient performs alone or with the doctor or physical therapist. The specific set of maneuvers is listed below:
1. From a sitting position, turn your head 45 degrees to the opposite side, then lay on the affected ear DOWN. Stare at an object about 8 feet away and wait for the dizziness to resolve and stay there for about 1 minute.
2. When the dizziness resolves, sit up and stare at the same object until the dizziness is over.
3. Then perform this in the opposite direction.
4. Repeat steps 1, 2, and 3 three times.
Occasionally, one is not able to fatigue or alleviate the dizziness. In those patients, the doctor may ask you to wear a soft cervical neck collar to limit the head motion.
There are various medications that may help to control the dizziness or nausea of this condition when the dizziness is quite active. Medication for this condition is not curative but helps to reduce some of the symptoms. Medication for this condition should not be used for more than a few days.
If the dizziness cannot be relieved with the conservative medical approach, surgery may be recommended to help alleviate the symptoms. There are 3 commonly accepted procedures to accomplish this:
1. Posterior semicircular canal plugging procedure
2. Singular nerve removal
3. Vestibular nerve clipping
This is discussed in another section of this report under surgical treatment of dizziness. In general surgery for this condition is very effective and helps to get the patient back to a relatively normal lifestyle free from the positional dizziness.