Benign Paroxysmal Positional Vertigo

Case Study

Case study: 45 years old university lecturer suffering from recurrent bouts of vertigo associated with certain head movements. His work was affected as during his lectures he used to get vertigo especially on turning around. He tried various medications with out much relief. He was diagnosed with BBPV and Epley's re-positioning maneouver was done, and symptoms completely resolved. He was also given home exercises in case it recurs again. The symptoms did recur again but he was able to treat himself with home exercises.

Benign paroxysmal positional vertigo is the most common causes of dizziness. It is a type of giddiness induced by various positions of the head. It is thought to be caused by tiny fragments or debris (calcium carbonate) in the posterior semicircular canal derived from the inner ear structure called Saccule. This debris was considered as ear "rocks", in the past they were called "otoconia". In many cases, this condition clears away on its own after several weeks. A simple treatment of moving the head into various positions over a few minutes and home exercises can cure this condition. This treatment uses gravity to move the debris away from where it is causing symptoms.

What is BPPV

It is a common condition of inner ear and is a frequent cause of dizziness in the outpatient clinics. It is widespread in all ages, much more common in older people.

• Benign means that it is not a serious condition. (The symptoms may be troublesome but the underlying cause is not serious.)
• Paroxysmal means recurrence of certain symptoms
• Positional means the symptoms of vertigo are produced by certain head positions
• Vertigo is dizziness with a spinning sensation. There is often association of feeling sick or actual vomiting

Causes

There is no single cause responsible for this condition, however causes can be attributed in about 40% and which include:

• Head injury
• Spontaneous degeneration of the labyrinth
• Post viral illness (viral neuronitis)
• Complication of Middle ear (stapes ) surgery
• Chronic middle-ear disease (infection)

Risk factors

• Age, onset most common between 40 and 60
• More common in women (M:F 1:2)
• Meniere's disease (co-diagnosis in up to 30%)
• Migraine
• There is usually a  history of  injury, infection, tiredness, recent travel and nausea

Activities that bring on BPPV

The activities which produce these symptoms vary in different people; however they are almost always triggered by a change in position of head with respect to gravity.

• When head is tipped backwards to look up hence called "Top shelf vertigo”.
• When head is tilted backwards on parlors shampoo bowl brings on the symptoms "Parlors vertigo”.
• Repeated attacks of vertigo after certain head movements (such as entailed in rolling over in bed, lying down, sitting up quickly, leaning forward or turning the head in a horizontal plane)

Symptoms

• Recurrent vertigo attacks are of sudden onset and usually last less than a minute
• Symptoms are typically worse in the mornings
• Nausea and vomiting
• Lightheadedness
• Balance problems
• Blurring of vision associated with sensation of vertigo
• Usually one ear is the worst, Patients often volunteer that symptoms are worse when the head is tilted to one particular side

Investigations

BPPV can be diagnosed from a careful look at the patients past history and from an examination without the need for further tests. Dix-Halpike manouver can confidently diagnose BPPV. In some cases the sign and symptoms are not very clear hence your doctor may order further tests e.g. electronystagmography (ENG) or viedonystagmography (VNG). These tests detect abnormal eye movements (nystagmus) caused by inner ear dysfunction if head is put in various positions or when your balance organ in the ear is stimulated with cold water. It uses electrodes on face around eyes or video recording to record the results. Scans of the brain including magnetic resonance imaging (MRI) or computerized tomogram (CT) to detect other serious conditions in the brain e.g. tumor, bleed etc.

Dix-Halpike manouver

Dix-Halpike manouver is done by extending the neck and then rotating the head towards one side first. At this position bring the patient down with head hangs down over the edge of the bed making an angle of 15-20degress. The patient is kept in this position for about one minute. If the test is positive, after a short pause you can see the nystagmus (involuntary movement of eye ball), this is associated with intense feeling of vertigo. It usually wears off in 20-30 seconds. When the nystagmus stops the patient sits up and symptoms can recur with the nystagmus beating in the opposite direction. The test is repeated on the opposite side if the first is negative.

Modified epley`s and home epley's manouver

Epley`s manouver is usually successful in relieving the symptoms of BPPV. It is best done in the clinic by an experienced clinician, however if the diagnosis is clear it can be done at home. Each position last for an average of 30 seconds. Modified epley`s manouver can be done at home and use pillow to adjust the position of head (overhanging the pillow). We recommend 3 cycles every night which will take less than 15 minute and it needs to be done daily until symptoms completely resolve. If the symptoms do not resolve completely with 2-3 weeks then a doctor should be consulted.

1. Sitting position.
   
2. Lying on the left side with head overhanging the pillow (if left ear is the "Bad ear”).
   
3. Lying on the back.
   
4. Lying on the right side
   
5. Sitting with "chin on chest”
   

Instructions after Epley`s manouver

After the above manouver following instructions should be followed to prevent recurrence of the vertigo symptoms. These precautions are usually necessary for about 1-2 weeks after the treatment.

• Immediately after the manouver wait for a few minutes before leaving the doctor`s office
• Try and keep your head vertical and avoid movements or exercises which involve head moving backwards. Have shower while standing and avoid bath and swimming
• Extreme care while visiting dentist, hair parlor, osteopath, massage and physiotherapist
• If eye drops are required avoid bending your head backwards
• Use 2 or 3 pillows at night and avoid lying on "Bad side”
• Start home exercises if there is no 100% improvement in vertigo symptoms about one week after the epley`s manouver done in the hospital

Brandt-Daroff Home Exercises

Brandt-Daroff are series of exercises that are done at home in the comfort of own bed. They are used if the epley's manouver do not provide 100% relief of the symptoms. These exercises are becoming less popular as home epley`s manouver appears to be working better. This is particularly useful when the "bad side” is not clear. It is done on average three times per day (morning, afternoon and evening) for 2-3 weeks. It will take 5 positions to complete one cycle i.e. sitting, lying on one side, sitting, lying on the other side, and sitting again. In the lying position try and keep focused at the ceiling. Each position should last for about 30 seconds. Most people get relief within one week of these exercises.

Advice for health care professional

• Dix-Halpike test can confidently diagnose BPPV
• The Modified Epley's manoeuvre can be done safely in clinic
• Instructions for Home Epley's manoeuvre and Brant-Daroff home exercises can be given from the clinic
• An anti-emetic e.g. stemetil, meclezine can be given for 1-2 days if nausea or vomiting is a real problem
• Sleeping at night with 2 or 3 pillows will help in preventing the vertigo in the morning

Advice for non-health care professional

• If after reading this information you feel that you are suffering from BPPV, home Epley's maneouver would be very useful in relieving your symptoms.
• During night time use at least two pillows
• After one week of Home Epley's maneouver if your symptoms are not 100% better you can do Brant-Daroff home exercises
• Before you  see a specialist keep a diary of your symptoms including aggravating and relieving factors, take a friend with you as after treatment your symptoms may be slightly worse, write down the question that you would like to ask the doctor
• Sit down if you feel dizzy
• If you get up at night , use good lighting
• Try and use a stick if the dizziness is bad
• Bring a friend with you for doctor`s appointment  who can take you home, as some patients vertigo symptoms can get worse for a few hours

What can I do if the maneouvers are unsuccessful or symptoms have recurred?

In our experience the above maneuvers are successful in over 95% of patients provided the diagnosis is made correctly. Some common causes of failure of maneouver treatment include:

• The diagnosis may have been wrong e.g. patient may have been suffering from central positional vertigo (causes in the brain), bilateral BPPV and rarely anterior canal BPPV. If it is BPPV it would get better with time
• The patient may have not performed the maneouvers correctly at home
• BPPV can recur after successful treatment by exercises in about 30 % of patients. Most recurrences (~80%) occur within the first year of treatment. These recurrences can be treated at home with Home Epley's manouver and Brant-Daroff exercises.
• In the remaining patients "habituations” exercises (vestibular rehabilitation training) may relive the symptoms completely, however if symptoms are intolerable inspite of the above exercises then definitive surgical management may offer a permanent cure.  

Surgical treatment

Surgery is reserved for the resistant and most severe cases. All procedures carry the risk of damaging the nerve. The various procedures include:

• Posterior canal plugging: It is the simplest of the all the other procedures. The posterior semicircular canal is surgically plugged. This prevents the loose particles from causing vertigo. This procedure has been reported to be successful in over 90% of cases with less hearing loss
• Singular (Posterior ampullary) and Vestibular Neurectomy: This involves surgically cutting of the nerve  that goes to part of the balance organ. It carries with the same risk as brain surgery as well as the possibility of injury to the hearing apparatus and the nerve to the face
• Labyrinthectomy: This is quite a destructive procedure which involves removing of the entire balance organ. It can be done chemically or surgically. This usually casus permanent deafness on the affected side.

Summary

BPPV is an extremely common cause of dizziness. It can be easily diagnosed and safely treated at home. The majority of patients get better with home exercises. It can recur again and usually respond well to home exercises. A minority of patients do require further treatment.

Further reading:

• Lee, NH, Ban, JH, Lee KC, Kim, SM. Benign paroxysmal positional vertigo secondary to inner ear disease. Otolaryngol Head Neck Surg 2010;143:413
• Hain, TC. http://www.dizziness-and-hearing.com. 27 Oct 2010
• Simhardi S, Panda N, Raghunathan M.  Efficacy of particle repositioning maneuver in BPPV: a prospective study: Am. J. Otolaryngol. 2003;24(6): 355-60
• Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol. Head Neck surg. 1992; 107(3): 399-404
• Semont T, Freyss G, Vitte E, Curing the BPPV with a liberatory maneuver. Adv. Otorhinolaryngol. 1988;42: 290-293
• Brandt T, Daroff RB,. Physical therapy for benign paroxysmal positional vertigo. Arch. Otolathinolaryngol. 1980;106(8):484-5
• Dix, Mr., Hallpike,CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol 1952; 61:987