What is it?
A distinguishing characteristic of BPPV is the onset of vertigo (spinning) with position changes. BPPV is due to misplaced debris that has collected in the wrong part of the inner ear. This debris, commonly called "ear crystals,” is composed of calcium-carbonate crystals. Patients typically associate their onset of vertigo with lying down, rolling over in bed, tilting their head back to look up and/or bending over. BPPV is the most common cause of brief spells of vertigo and is frequently accompanied with feeling unsteady and even nausea. The duration of the vertigo is typically less than 60 seconds in nature, is often worse when rolling over onto one side and is described as sensation of the “room spinning.”
What causes BPPV?
The causes of BPPV are often unknown. However, BPPV is more common following head trauma, an illness (e.g., inner ear infection), and/or a sudden change in the fluid of the inner ear. Providers who specialize in the assessment and treatment of BPPV note a high reoccurrence associated with seasonal allergies and, in some patients, barometric pressure changes. BPPV also tends to occur more frequently in women than men and also increases in frequency as we age. Although BPPV is frequently associated with head trauma, this condition rarely occurs in adolescents. Positional vertigo in the younger populations may be due to migraines or even a more serious neurological condition.
How is BPPV diagnosed?
The diagnosis of BPPV is determined by the patient's symptoms and/or positive findings with specific positional testing, which is most widely known as the Dix-Hallpike. Testing can be further confirmed with videonystagmography (VNG), which is a diagnostic test specific to dizziness and imbalance issues. Although BPPV can occur by itself, it is most commonly seen with other inner ear disorders. Therefore, additional balance and hearing tests may provide comprehensive information about any underlying cause(s) of BPPV.
How is BPPV treated?
A series of movements known as “repositioning maneuvers” are the most effective treatment for BPPV. These procedures are ideally performed by a trained clinician and include moving the patient through a series of specific positions to move the crystals back into a proper place of the inner ear. The maneuver is specific to the right or left ear(s), the canal(s) involved, and the type of BPPV that exists. For example, BPPV may occur in one or both ears, one or more of the semicircular canals, and may be “free floating” within the canal or adhering to a part of the canal. The most common canal involvement is the posterior canal, which typically responds well to the Epley maneuver. The horizontal canal may also be affected and is treated with the Roll, or “barbeque roll,” maneuver. BPPV can successfully be treated in 1-2 visits more than 90% of the time (see image above).
An alternate treatment if the maneuvers are not successful is Brandt-Daroff exercises. However, exercises are not the preferred treatment, especially initially. A newer treatment, referred to as the “Foster” or “half somersault” maneuver has become increasingly popular from a YouTube video. However, this maneuver has not shown to be more successful than the Epley maneuver and requires more flexibility and even strength. This maneuver should be used with caution considering potential risk for injury. Surgery is rarely used to treat BPPV but may be necessary is a very small number of cases and is performed by an ENT specialist.
When the maneuvers are used, the patient may be asked to follow a specific set of home instructions for the next 48 hours, such as not lying flat, sleeping on the affected side and avoiding excessive head movements (looking up or down). Although a study indicated the 48 hour precautions following a treatment do not significantly improve the success rate, the majority of clinicians who specialize in this treatment disagree and do recommend the precautions.
Keep in mind that the maneuvers are very successful with the appropriate treatment. However, there is a fairly high reoccurrence rate (>45%) within a couple of years. Also, it is not uncommon to have additional symptoms of imbalance and/or movement-related dizziness even after the BPPV is resolved. Specific exercises (commonly referred to as “vestibular rehabilitation”) are highly effective in addressing the residual symptoms related to vestibular dysfunction. Of course, if there are additional issues to address (e.g., loss of strength, decreased flexibility, pain and/or weakness) then specific exercises can be part of the vestibular rehabilitation program as well. For those clinicians working with patients following head trauma, assessing cognition and the oculomotor (eye movements) system is as equally important and specific exercises may also need to be integrated into their recovery program.
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