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Benign Paroxysmal Positional Vertigo

Benign Paroxysmal Vertigo


Presentation

BPPV presents with the following symptoms:

  • Dizziness and a feeling of spinning
  • Feeling that the surroundings are spinning around
  • Nausea
  • Vomiting
  • Loss of balance
  • Tinnitus 
  • Visual problems
  • Head ache
  • Limited duration of symptoms: usually <20 seconds/episode 
  • Reversal of symptoms once upright position is maintained.

Symptoms appear suddenly, such as when the patient tries to sit up after sleep, when there is sudden tilting of the head to see something above, etc. and go away rapidly too.

Nausea
  • Peripheral vestibular disorders result in vertigo, disequilibrium, and frequently nausea and vomiting.[ncbi.nlm.nih.gov]
  • The canalith repositioning procedure, a series of defined head positions, is designed to shift the location of the otoliths to afford relief from the nausea, vomiting and dizziness often experienced by patients with this disorder.[ncbi.nlm.nih.gov]
  • This article describes and discusses the case of a patient with benign paroxysmal positional vertigo (BPPV) characterized by severe vertigo with dizziness, nausea, and nystagmus, treated without the use of spinal manipulation by a doctor of chiropractic[ncbi.nlm.nih.gov]
  • A 49-year-old female suffered intense vertigo and nausea immediately after implant placement using an osteotome sinus floor elevation procedure, especially when changing head position while sitting upright.[ncbi.nlm.nih.gov]
  • BPPV presents with the following symptoms: Dizziness and a feeling of spinning Feeling that the surroundings are spinning around Nausea Vomiting Loss of balance Tinnitus Visual problems Head ache Limited duration of symptoms: usually 20 seconds/episode[symptoma.com]
Vomiting
  • BPPV presents with the following symptoms: Dizziness and a feeling of spinning Feeling that the surroundings are spinning around Nausea Vomiting Loss of balance Tinnitus Visual problems Head ache Limited duration of symptoms: usually 20 seconds/episode[symptoma.com]
  • Peripheral vestibular disorders result in vertigo, disequilibrium, and frequently nausea and vomiting.[ncbi.nlm.nih.gov]
  • The canalith repositioning procedure, a series of defined head positions, is designed to shift the location of the otoliths to afford relief from the nausea, vomiting and dizziness often experienced by patients with this disorder.[ncbi.nlm.nih.gov]
  • The patient suffered with intense vertigo with nausea, vomiting, and aggravated when she changed the position of her head towards right immediately after procedure and was diagnosed with BPPV after the referral.[ncbi.nlm.nih.gov]
  • Antiemetic medicines, such as promethazine (Histantil), may be used if you have severe nausea or vomiting.[healthlinkbc.ca]
Benign Paroxysmal Positional Vertigo
  • Benign paroxysmal positional vertigo is characterized by brief episodes of mild to intense dizziness.[web.archive.org]
  • BACKGROUND: Benign paroxysmal positional vertigo and migraine-associated dizziness are common. The prevalence of benign paroxysmal positional vertigo seems to be higher in patients with migraine-associated dizziness than in those without migraine.[ncbi.nlm.nih.gov]
  • Benign paroxysmal positional vertigo causes brief episodes of mild to intense dizziness. Benign paroxysmal positional vertigo is usually triggered by specific changes in the position of your head.[mayoclinic.org]
  • Why do benign paroxysmal positional vertigo episodes recover spontaneously? J Vestib Res 1998 ;8: 325 – 29. Google Scholar Medline ISI 28. Brand, Th, Daroff, RB Physical therapy for benign paroxysmal positional vertigo.[doi.org]
  • Hughes CA, Proctor L: Benign paroxysmal positional vertigo. Laryngoscope 1997, 107 :607–613. PubMed CrossRef Google Scholar 11. Gizzi M, Ayyagari S, Khattar V: The familial incidence of benign paroxysmal positional vertigo.[doi.org]
Tinnitus
  • A 69-year-old woman, with no history of vertigo attacks, presented with the classical triad of symptoms for Ménière's disease in the right ear (vertigo, tinnitus, fullness).[ncbi.nlm.nih.gov]
  • A high percentage of patients also had hearing loss (42.9%), tinnitus (41.2%), or both (26.8%).[ncbi.nlm.nih.gov]
  • (4) Have you previously experienced hearing loss in one ear, or have you experienced hearing loss, tinnitus, or ear fullness with this D/V? One point each was given to an answer of 'yes' to questions (1) and (2).[ncbi.nlm.nih.gov]
  • Hearing is not affected and tinnitus is not a feature. Symptoms such as hearing loss, tinnitus, ear or mastoid pain, headache and photophobia point towards alternative diagnoses.[patient.info]
  • BPPV presents with the following symptoms: Dizziness and a feeling of spinning Feeling that the surroundings are spinning around Nausea Vomiting Loss of balance Tinnitus Visual problems Head ache Limited duration of symptoms: usually 20 seconds/episode[symptoma.com]
Panic Attacks
  • Margraf J, Taylor B, Ehlers A, Roth WT, Agras WS (1987) Panic attacks in the natural environment. J Nerv Ment Dis 175:558–565 PubMed CrossRef Google Scholar 40.[doi.org]
Vertigo
  • RESULTS: The percentage of patients with dizziness or vertigo who met criteria for migraine was 33.7 per cent, with a prevalence of benign paroxysmal positional vertigo of 42.3 per cent.[ncbi.nlm.nih.gov]
  • Brandt T, Steddin S, Daroff RB: Therapy for benign paroxysmal positioning vertigo, revisited. Neurology 1994, 44 :796–800. PubMed Google Scholar 28. Vrabec JT: Benign paroxysmal positional vertigo and otolith repositioning.[doi.org]
  • Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo — the sudden sensation that you're spinning or that the inside of your head is spinning.[web.archive.org]
  • Abstract Benign paroxysmal positional vertigo is the most common peripheral vestibular disorder. It can be defined as transient vertigo induced by a rapid head position change, associated with a characteristic paroxysmal positional nystagmus.[doi.org]
  • Overview Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo — the sudden sensation that you're spinning or that the inside of your head is spinning.[mayoclinic.org]
Nystagmus
  • "Nystagmus intensity" evaluation allows distinguishing the geotropic variant from the apogeotropic one, while the "nystagmus direction" allows identification of the side.[ncbi.nlm.nih.gov]
  • The provocative positions usually trigger specific eye movements (ie, nystagmus). The character and direction of the nystagmus are specific to the part of the inner ear affected and the pathophysiology.[emedicine.com]
  • SSC BPPV is distinguished from the more common posterior semicircular canal (PSC) variant by the pattern of nystagmus triggered by the Dix-Hallpike position: down-beating torsional nystagmus in SSC BPPV versus up-beating torsional nystagmus in PSC BPPV[ncbi.nlm.nih.gov]
  • Nystagmus can occur spontaneously from multiple causes. Direction-changing positional nystagmus on the supine roll test is a characteristic clinical feature in horizontal semicircular canal benign paroxysmal positional vertigo.[ncbi.nlm.nih.gov]
  • Down-beating positional nystagmus is typically associated with central nervous system disease.[ncbi.nlm.nih.gov]
Dizziness
  • […] and Dizziness Handicap Index suggests that addition of balance VRT does not influence dizziness symptomatology, per se, and CRM alone is effective to ameliorate vertiginous symptoms and potentially improve quality of life.[ncbi.nlm.nih.gov]
  • We analyzed how various general factors and ocular vestibular evoked myogenic potentials related to residual dizziness.[ncbi.nlm.nih.gov]
  • Dizziness in the elderly is a serious health concern due to the increased morbidity caused by falling.[ncbi.nlm.nih.gov]
  • The dizziness usually only lasts a short while – for a few seconds to five minutes at the most. You may feel nauseous during and after an episode of dizziness, and in rare cases it may cause vomiting.[ncbi.nlm.nih.gov]
Headache
  • Symptoms included spinning vertigo lasting for 30's, headache, visual vertigo and disorientation.[ncbi.nlm.nih.gov]
  • METHODS: A database of 508 patients seen at the primary author's balance clinic was analysed to determine the prevalence of migraine, as defined by International Headache Society criteria, in patients with benign paroxysmal positional vertigo.[ncbi.nlm.nih.gov]
  • There have been reports of negative side effects in users of this equipment, such as dizziness, headache and a sensation of imbalance; however, there have been no reported cases involving vertigo.[ncbi.nlm.nih.gov]
  • International Headache Society Classification Subcommittee (2004) International classification of headache disorders. 2nd edition. Cephalalgia 24(Suppl 1):1–160 Google Scholar 29.[doi.org]
  • Seek emergency care Although it's uncommon for dizziness to signal a serious illness, see your doctor immediately if you experience dizziness or vertigo along with any of the following: A new, different or severe headache A fever Double vision or loss[mayoclinic.org]
Stroke
  • We also identified the comorbidities of the patients with BPPV, including head trauma, osteoporosis, migraine, hypertension, diabetes, hyperlipidemia and stroke. These variables were then compared to those in age- and gender-matched controls.[ncbi.nlm.nih.gov]
  • These are potential signs of a stroke . If there is fever associated with vertigo, there may be an infection as a potential cause of symptoms.[emedicinehealth.com]
  • (Breast stroke is OK.) Also avoid far head-forward positions such as might occur in certain exercises (i.e. touching the toes).[entsurgicalillinois.com]
  • However, in people who have vertigo due to a brain disorder (such as stroke or multiple sclerosis), which is more serious, the Dix-Hallpike maneuver triggers symptoms immediately, the vertigo persists as long as the head is held in the same position,[msdmanuals.com]
  • Cerebrovascular disease - transient ischaemic attack (TIA) , stroke . Posterior cranial fossa tumours - eg, acoustic neuroma . Brainstem lesions. Herpes zoster oticus (Ramsay Hunt syndrome) . Otosclerosis . Vertebrobasilar insufficiency .[patient.info]

Workup

Work up consists of a detailed history and physical examination.

Laboratory Tests

  • Dix-Hallpike manoeuvre: It is a common test performed by examiners to determine whether the posterior semicircular canal is involved [6]. This test will reproduce vertigo and nystagmus characteristic of BPPV [7].
  • Roll test: This test can be performed to check the involvement of the horizontal semicircular canal. In this test, the patient lies in a supine position with his head cervically flexed at 20 degrees. The examiner then quickly rotates the patients head 90 degrees to one side. Nystagmus and other symptoms are checked. Then the examiner brings the patient's head back to initial position and rotates the head 90 degrees to the opposite side this time. Symptoms associated with BPPV are checked again.
  • Electronystagmography may also be performed.

Imaging 

Imaging studies are not required to diagnose BPPV. A CT scan [8], however, may be conducted if needed to check for other suspected pathologies.

Test results

A physical examination and history are sufficient to diagnose BPPV.

Treatment

Canalith repositioning procedure

The Epley maneuver is done by a series of 4 movements of the head. After each movement, the head is held at the same place for 30 seconds or so [9]. This is a highly effective, risk-free and non invasive mode of treatment and considered the treatment of choice for BPPV. There are other maneuvers also that are included in the CRP but are less effective and less popular than the Epley maneuver.

Vestibulosuppressant medications

These are not very effective as they do not treat the condition but just provide temporary relief.

Surgery

This is the last mode of treatment reserved only for those patients in whom CRP (canalith repositioning procedure) has completely failed and who suffer from very severe episode of vertigo that greatly compromise quality of life.

Prognosis

As the name indicates, BPPV comes and goes. It may get triggered due to movement and an episode of vertigo may occur. In most cases, BPPV can be treated by the Epley maneuver and prognosis is very good. In some cases, episodic recurrence may happen.

Complications

Complications are extremely uncommon. Rare cases may include dehydration due to repeated episodes of vomiting and trauma secondary to loss of balance due to BPPV.

Etiology

BPPV occurs due to a defect in the inner ear. Recall that the inner ear has fluid filled semicircular canals and otoliths. A small fragment of the otolith may break apart and its motion brought upon by movement of the head, may send inappropriate signals to the brain regarding the body's balance and position.

Other causes include age related wear and tear of the inner ear, trauma to the ear which damages the vestibular organs, ear diseases such as otosclerosis, otitis media and Meniere disease. CNS diseases may cause secondary BPPV. However, up to 39% of cases are idiopathic.

Epidemiology

Incidence

Approximately 18% of patients seen in dizziness clinics [2] and 25% of patients seen for vestibular testing have BPPV [3].

Age

Although BPPV can occur at any age, it most commonly presents in patients aged 60 and above. BPPV also accounts for about 20% of paediatric referrals [4].

Sex
BPPV shows a distinct predisposition in females (up to 64% some studies reveal).

Race

BPPV has no known predisposition to any race or ethnic group.

Sex distribution
Age distribution

Pathophysiology

BPPV is an abnormal sensation of motion that is brought upon by certain movements of the head and/or eyes. These movements or positions may lead to nystagmus which then leads to dizziness and vertigo.

The sensation of fluid moving in the semicircular tubes tells the brain the position of the body [5]. If these sensations are abnormal, they may send wrong or mixed signals to the brain and dizziness and vertigo may be triggered.

Prevention

Patients may want to adjust their sleeping positions accordingly to prevent recurrence [10]. Rehabilitation may prove to be helpful and slight changes in daily behaviour and routine may help in preventing recurrence of BPPV.

Summary

Benign paroxysmal positional vertigo (BPPV) is the most common form of vertigo. Its symptoms are repeated episodes of positional vertigo, that is of a spinning sensation caused by changes in the position of the head [1]. It is due to a defect in the inner ear which may occur due to a number of causes and this condition may act as a source of discomfort for a life time in some cases.

Patient Information

Definition

BPPV is the most common type of vertigo that occurs due to inner ear defects.

Cause

It is mostly idiopathic but it can also occur due to trauma, ear diseases, CNS diseases, old age, etc.

Symptoms

BPPV presents with characteristic nystagmus, dizziness, nausea, vomiting, headache and loss of balance.

Treatment

BPPV can be treated by physical maneuvers performed by trained professionals and in severe cases, surgery can provide relief.

Prevention

BPPV is triggered due to unprecedented movement of the head and/or eyes so it can be prevented by modifying movements and sleeping positions.

References

Article

  1. Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston L, Cass S, Chalian A, Desmond A, Earll J (2008). Clinical Practice Guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 139 (5 Suppl 4):S47-81.
  2. Nedzelski JM, Barber HO, McIlmoyl L. Diagnosis in a dizziness unit. J Otolaryngol 1986;15:101.
  3. Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Laryngoscope 1997;107:607.
  4. Wiener-Vacher SR. Vestibular disorders in children. Int J Audiol. 2008;47:578.
  5. Crane BT, Schessal DA, Nedzelski J, Minor LB. Peripheral vestibular disorders. In: Cummings CW, Flint PW, Haughey BH, et al, eds. Otolaryngology. Head and Neck Surgery. 5th ed. Philadelphia. Pa: Moseby Elsevier 2010:chap 165.
  6. Korres SG, Balatsouras DG, (2004). Diagnostic, pathophysiologic and therapeutic aspects of benign paroxysmal positional vertigo. Otolaryngology- Head and Neck Surgery 131(4):438-44. doi: 10.1016/j.otohns.2004.02.046. PMID 15467614.
  7. Schubert M.C (2007). Vestibular Disorders. In: S.O'Sullivan & T Smchidz, eds. Physical Rehabilitation. 5th ed. Philadelphia. Pa: FA Davis Company. pp999-1029.
  8. Post RE, Dickerson LM. Dizziness:a diagnostic approach. Am Fam Physician. 2010;82:361-369.
  9. Glasziou P, Bennett J, Greenberg P, et al. The Epley Maneuver: for benign paroxysmal positional vertigo. Aust Fam Physician. 2013 Jan-Feb;42(1-2):36-7.
  10. Shim DB, Kim JH, Park KC, Song MH, Park HJ. Correlation between the head-lying side during sleep and the affected side by benign paroxysmal positional vertigo involving the posterior or horizontal semicircular canal. Laryngoscope. Feb 16 2012 [Medline]. 

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Last updated: 2019-07-11 20:00