Benign Paroxysmal Positional Vertigo

By: James Prueter, DO

Positional vertigo is a spinning sensation caused by a change in head position in relation to gravity. Benign paroxysmal positional vertigo, or BPPV, is a disorder of the inner ear. BPPV is the most common cause of vertigo. Symptoms can range from mild dizziness to more severely debilitating attacks with nausea, vomiting, and increased risk of falling, all of which disrupt daily activity. BPPV is caused by irregular signals being sent from the semi-circular canals in the inner ear causing an illusion of motion.

There are two theories as to what causes this irregular signaling: one theory is that endolymphatic debris adheres to a part of the inner ear called the cupula causing it to become highly sensitive to gravity and motion (cupulolithiasis). The second predominating theory is that there are free-floating particulates in the semi-circular canals themselves and when gravity pulls at that debris during head movement, the force displaces the cupula, thus causing abnormal signaling (canalithiasis). If one ear is sending this incorrect information to the brain while the unaffected ear, eyes, and musculature of the head and neck are sending normal signals, the conflicting information is interpreted as vertigo. The source of this inner ear debris is still up to debate.

How Does BPPV Develop?

BPPV is a common disease in adults, being more common in seniors and rare among children.
BPPV is usually idiopathic, meaning that there is not a known specific cause of the disease. However, there are causes of BPPV that are secondary to other diseases or injuries. Migraine, vestibular neuritis, and Meniere’s disease have all been shown to have the ability to produce BPPV in patients. Similarly, head trauma appears to also be a cause of BPPV, along with otologic and non-otologic surgery alike. The theory behind these mechanisms and diseases causing secondary BPPV is that all these modalities in one way or another dislodge or degrade the otoconia leading to aberrant signaling to the brain.

How Is BPPV Diagnosed?

Generally, family practice physicians may not be familiar with the testing and diagnostic processes involved with conditions such as BPPV, so they may refer patients to an otolaryngologist who has been specifically trained in diagnosing and treating vestibular disorders. Diagnosis depends on the occurrence of vertigo and on noting the torsional and upbeat nystagmus during the Dix-Hallpike maneuver (the gold standard test for BPPV caused by debris in the posterior semi-circular canal). There is another diagnostic test called the Roll Test (also called the Pagnini-McClure maneuver) that tests for horizontal BPPV (caused by debris in the horizontal semi-circular canal). Posterior canal BPPV is more common than horizontal canal BPPV. It is also possible to have multiple semi-circular canals affected at the same time, usually caused by head trauma, thus making accurate diagnosis even more important.

How Is BPPV Treated?

In most cases, BPPV can be treated in the office with head movements guided by the physician, or a physical therapist trained in vestibular therapy. Once an accurate diagnosis is made regarding which canal is being affected and which variant of BPPV the patient has, the provider can guide the patient through certain movements to treat them. The basis behind these treatments is similar: the goal is to move the otoliths (crystals) back to the part of the inner ear where they belong (the utricle). These movements are called Canalith Repositioning Maneuvers (ex. the Epley maneuver or Semont maneuver). In the case of cupulolithiasis, a technique called the Liberatory Maneuver must be performed first to dislodge the otoliths from the cupula. From this point, they can then be guided back to the utricle. These treatments have a high success rate, though recurrence of BPPV is still possible.

Medications are typically not used for BPPV because it tends to resolve on its own within a few weeks after initial onset.

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