Benign Paroxysmal Positional Vertigo

Definition, causes and effect to the victim

What is Benign Paroxysmal Positional Vertigo (BPPV)?

The major characteristics f this condition is brief recurrent episodes of vertigo. This vertigo is triggered off by the way the patient places hisorchis or her head  during sleep.
Benign Paroxysmal Positional Vertigo is the major cause of recurrent vertigo. BPPV is characterized by the feeling of recurrent episodes of vertigos—a false feeling of spinning in the head. The main cause of this condition is the abnormal arousal of the cupula by free-floating otoliths (canalolithiasis). This condition can also occur when otoliths adhere (hang up) to the cupula (cupulolithiasis) surrounded by any of the three semicircular canals. These can also be referred to as the two types of BPPV.
 
Benign Paroxysmal Positional Vertigo is not life threatening and can be easily treated in the doctor’s office. This condition occurs in sudden bursts and the effect also lasts for a short time. Benign Paroxysmal Positional Vertigo is mainly triggered by positioning the head is such a way that the affected semicircular canal of the ear is spatially erect in such a way that it aligns to gravity.
 
Benign Paroxysmal Positional Vertigo is very common and forms the major cause of dizziness. About 90% of positional vertigo have been ascribed to BPPV. There are situations where the vertigo can be serious however, this situation is rare. However, the more severe the condition, the greater your chances of falling.
 

During a BPPV incident what really happens?

BPPV can be referred to a mechanical problem that occurs in the inner ear. This problem occurs when some of the calcium carbonate crystals known as the otoconia which are normally contained in the utericle gel dislodges and makes its way into one of the 3 semicircular canals filled with fluid.
Accumulation of these crystals in one of the canals will lead to an interference in the normal fluid movement that enables these canals to measure the movements of the head. This causes the inner ear to falsely alert the brain on movement. Normally, the fluids in the semicircular canal of the ear do not react to gravity. On the other hand, the crystals move with gravity. This crystal movement will cause the fluid to move when normally it is supposed to be still. This movement will arouse the nerve ending which sends a false signal of head movement to the brain.
The problem arises because the false information is only sensed by one ear alone and does not correspond with what the other ear is sensing, it also does not correspond with the vision as well as what the muscles and joints are perceiving. As a result of this mismatch, the brain perceives the false information as a spiral sensation of the head (vertigo). Vertigo normally last only about a minute and often without symptoms. However, others may feel a slight sensation of imbalance or instability.
It is important to keep in mind that BPPV will not affect your hearing in any way or cause you dizziness that is not affected by the change in position. BPPV will also not cause you to feel headaches of a fainting sensation or even neurological signs such as numbness, poor movement coordination or speech problems. Therefore, in case you notice any of these signs, it is important to report it to your doctor. Perhaps you may be suffering from a more severe condition that has been wrongly diagnosed as BPPV.
Informing your doctor on other conditions that you are experiencing alongside your vertigo will help the doctor re-evaluate your situation. This can help determine whether you are suffering from other underlying medical conditions.

Who is mostly affected by BPPV?

BPPV has an estimated occurrence in 107 per 100,000 people per year and a lifetime occurrence of about 2.4 percent making it a fairly common condition. BPPV is rarely found in children however, it is common if adults of any age but more common in those of advanced age.
In most cases, BPPV have been found to occur for no specific reason. Most people who experienced BPPV simply agree to the fact that they try to get out of bed one morning and the room suddenly begins to spin. Nonetheless, research have found out that vertigo can occur as a result of conditions such as an ear infection, trauma, migraine, diabetes, osteoporosis, reduced blood flow and intubation (which may be as a result of lying in bed for too long). Vertigo can also have a connection with one’s preferred sleeping side.

What are the common triggers of BPPV?

There are a number of activities that can trigger BPPV. These include:

• The way you get in and out of bed


• Rolling in bed


• Bending over


• Sudden quick head movements


• Tipping the head backwards

Moving in the above mentioned ways can trigger vertigo. If you notice any form of dizziness or develop a feeling of the room spinning after performing any of the above movements then you might be suffering from BPPV.
Nystagmus (rhythmic eye movements) usually accompany BPPV and in most cases, that is what the doctor will be watching out for.

What is the next step to take if you notice any signs of vertigo?

If you notice that you are experiencing dizziness that usually comes suddenly and goes off in a short time for over a period of one week, it is important to talk to the doctor. There are however, certain steps you can take at home to determine which of your ears is affected before going to see the doctor. Do the following:

• Sit on your bed in such a way that your head hangs over the edge when you lie down.


• Rotate your head quickly to the right and lie down quickly.


• Wait for a minute. Did you feel dizzy? If the answer is yes then the right ear is affected.


• If you did not feel dizzy, you need to sit up again, wait for about 5 minutes before repeating the exercise with the left ear.


• If you noticed that you felt dizzy when you repeated the exercise on the left ear then the left ear is affected.

Once you have noticed any of the common signs of BPPV, it is important to see your family doctor. While some doctors are familiar with the testing process for BPPV, others may not be familiar with it and therefore, your family doctor will refer you to a medical professional who is trained to handle vestibular conditions. This may be a vestibular rehabilitation therapist (this person is specially trained physical therapist. Other times, it might be an audiologist or an occupational therapist) or ENT (ear, nose and throat specialist). They can be found in most hospitals and a lot of them specialize in vestibular disorder.
It is sad enough to say that some doctors are still not aware that there are very effective treatments for vertigo. They wrongly advice their patients to lie with the condition with the hope that they get better naturally. This however, is not in line with best practice.

Carrying out diagnoses for vertigo

Carrying out diagnosis for BPPV requires placing the head in some specific positions and watching out for specific eye movements known as nystagmus. The use of normal medical imaging is less effective in diagnosing BPPV. This is due to the fact that normal medical imaging like MRI will not show the crystals in the semi-circular canal.
The first thing most doctors will generally do is to ask about your general medical history and the current symptoms you are experiencing. The doctor may request you to lie down with your head tilted backwards.
The head tilt method of diagnosis is very effective because the eye muscles and the inner ear are closely connected allowing us to focus on the environment when our head is moving. When the head is tilted, the dislodged crystals move causing the brain to think that the head is moving. This will cause the eyes to move as well. This is the major reason why the room feels like it is spinning. The eye movement is one way to identify that there is a mechanical problem causing the inner ear fluid in the inner ear canal to move when it is not supposed to moving.
There are different characteristics of nystagmus that will allow the professional to recognize the ear in which the dislodged crystals are and the specific canals they have moved into. The Dix-Hallpike test or the Roll Test can be used to identify the specific canal the crystals have moved into. This test involves moving the head in different specific orientations that will cause gravity to move the dislodged crystals thereby triggering vertigo while the trained practitioner takes note of the eye movements.
This test can determine what kind of BPPV you are suffering from. In the case of canalithiasis, the crystals will generally stop moving in less than one minute causing the nystgmus and vertigo to stop. In the case of cupulolithiasis, the stuck crystals will cause the vertigo and nystagmus to last much longer. In most cases, the head have to be moved out of the offending position before the nystagmus or vertigo will stop. Identifying the exact type of BPPV is very important because the treatment for both types are not the same.

Treatment of Benign Paroxysmal Positional Vertigo (BPPV)

There are no evidences that the use of medication for the treatment of BPPV is effective. However, a lot of people are given medication when they experience BPPV. There are extreme rare cases in which surgery may be required for the correction of BPPV.
Most professionals rely on mechanical method to correct BPPV. Once the healthcare professional identifies the kind of BPPV and the canal(s) the crystals are in, they can choose the appropriate treatment procedure. The mechanical process makes use of gravity to guide the crystals back to their proper chamber through very precise head movements known as the Canalith Repositioning Maneuvers (CRM).
When it comes to cupulolithiasis, the doctor would first try to dislodge the ‘hung up’ crystals through swift head movements in the plane of the affected ear canal. This process is known as the Liberatory Maneuver. Once this is successful, the CRM will then be performed.
There is another kind of maneuver that is effective for the most common location and the different kinds of BPPV. This type of maneuver is called the Epley maneuver.
There are cases where people attempted a self-maneuver at home without success. Therefore, self-maneuver is highly discouraged because often times, it is discovered that the wrong kind of maneuver was used by the patient. It is therefore important that any kind of maneuver should be diagnosed and performed by a professional who is well trained to handle BPPV cases with full knowledge of how to apply each kind of maneuver.
Before proceeding with treatment for BPPV, it is important to first perform a careful neurological scan and carefully evaluate the neck of the patient. Other investigations in regards to the procedure should also be carried out to ascertain whether some basics elements of the process needs to be altered or be left out entirely. This is one of the reasons why self-maneuver or treatment by a nonprofessional is strongly discouraged.

Rehabilitation

Sometimes, the repositioning maneuver might fail or other times, patients will not be able to tolerate the repositioning maneuver, the Bandt-Daroff exercise will be attempted. This exercise can be repeated continuously until the symptom is resolved.

Surgical procedure

In some cases though rare, even with CRMs and Bandt-Daroff exercise, the patient might suffer from continuous spells of disabling positioning Vertigo or the frequent reoccurrence that are noncompliant to repositioning maneuver. When this case occurs, the only option to be considered will be a surgical procedure.
Transection of the posterior ampullary nerve innervating the posterior canal (singular neurectomy) or the occlusion of the semicircular canal (canal plugging) have been done for intractable PC-BPPV.
Gacek in 1974 described singular neurectomy as an active technique that was designed to regulate the symptoms of intractable BPPV which harbors the acceptable risk of a hearing loss. Canal occlusion and canal plugging are also very effective techniques and also shows lower risk of hearing loss.
Using surgical procedures should always come last. CRM and Bandt-Daroff exercise must have been attempted and failed before a surgical procedure will be recommended.

Managing BPPV Medically

The use of antihistamine and benzodiazepine (vestibular suppressants) are not suggested for BPPV patients. There are two major reasons why medication may be prescribed by clinicians.

• To suppress the spinning sensation of vertigo


• Lessen the symptoms of motion sickness that accompanies vertigo.

Notwithstanding, none of the vestibular suppressants are as effective as the CRM when it comes to the treatment of BPPV. Vestibular suppressants can therefore not be used as a replacement for CRM.
Antivertiginous drugs can be prescribed to reduce the symptomatic relief of nausea and dizziness before proceeding to carry out a CRM.

Recurrence and Projection

There is often the recurrence of vertigo in BPPV with the reported rates of about 15-37% after the effective administration of CRM. According to more recent studies, the recurrent mean rate is 50% for a period of 10 years. These recurrences (80%) are often within the first year after treatment.
Some of the factors that lead to higher recurrent rates includes the presence of a trauma, factors such as being female, labyrinthitis and endolymphatic hydrops. The presence of osteopenia or osteoporosis and HC-BPPV can also be a cause of recurrence.
On the other hand, someone with a history of three or more BPPV attacks before treatment is more likely to experience a reoccurrence.

Risk Factors of BPPV

Benign Paroxysmal Positional Vertigo (BPPV) is mostly noticed among adults of advanced ages (50 and above). Women are at greater risk of suffering from the condition than their male counterpart. An injury to the head or other kinds of infection or problem that affects the balance organs of the ear can put you at greater risk of suffering from BPPV.

Complications

Benign paroxysmal Posotional Vertigo (BPPV) can be very uncomfortable. BPPV can cause dizziness which greatly puts you at the risk of falling. Nonetheless, there are rarely any complications that can occur as a result of BPPV.

What home remedies can I take after the treatment of BPPV?

It is important to understand that even after you have successfully treated BPPV, there can always be a reoccurrence. This is why it is important to follow these home remedies to ensure a reoccurrence does not happen.

• Know that your chances of falling are high after a BPPV treatment.


• Learn to sit down whenever you feel dizzy.


• Always ensure you use good lighting in your room when you wake up at night.

What if your BPPV reoccurs, there are various steps you can take to help remedy the symptoms while you wait to see your doctor.

• Don’t sleep on the affected side of the ear.


• Join two or three pillows together under your head when going to bed.


• Avoid getting up immediately you wake up. Learn to sit up slowly and relax on the side of the bed for a while before standing up.


• Be careful of the way you bend over to pick up things from the floor. It is more advisable to avoid it completely.

In some cases, the doctor might also teach you some maneuver you can practice at home to help ensure move the crystals back in place.

Conclusion

Benign Paroxysmal Positional Vertigo (BPPV) is not something new to us. It is common and we will see more of this condition as our population continues to grow older.  The influence of this condition can range from a mild irritation to a highly unbearable condition. This can have some implications on safety, function and the risk of a fall.
The symptoms of Benign Paroxysmal Positional Vertigo tend to be less severe due to the fact that after some times, the brains begins to slowly adjust to the irregular signals it receives. In other cases, the condition might spontaneously get resolved without requiring any form of treatment.
Nonetheless, patients who were treated by professionals who are trained to handle BPPV cases are glad to have received treatment from hem. They recover faster. They are pleased that their condition was resolved faster than they expected.
 
 

References

Lee, Seung-Han & Kim, Ji. (2010). Benign Paroxysmal Positional Vertigo. Journal of clinical neurology (Seoul, Korea). 6. 51-63. 10.3988/jcn.2010.6.2.51.
Froehling DA, Silverstein MD, Mohr DN, et al. Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota. Mayo Clin Proc 1991;66:596–601.
Bhattacharyya N et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 139(5 Suppl 4):S47-81, 2008.
Fife TD, et al. Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review): Report on the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70:2067-74.
von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry 2007;78:710–5.