Benign paroxysmal positional vertigo
| Benign paroxysmal positional vertigo | |
|---|---|
| Specialty | Otorhinolaryngology  |
| Frequency | 2.4% |
Benign paroxysmal positional vertigo (BPPV) or benign paroxysmal vertigo (BPV) is a disorder caused by problems in the inner ear. Its symptoms are repeated episodes of positional vertigo, that is, of a spinning sensation caused by changes in head position.[1]
Classification
Dizziness accounts for about 6 million clinic visits in the U.S. every year, and 17–42% of these patients eventually are diagnosed with BPPV.[1] Other forms of vertigo include:
- Motion Sickness: A disjunction between visual stimulation and proprioception
- Visual exposure to nearby moving objects (examples of optokinetic stimuli: cars, snow, shopping aisles)
- Any other causes of vertigo (labyrinthitis, Ménière's disease etc)
Cause
Within the labyrinth of the inner ear lie collections of calcium crystals known as otoconia. In patients with BPPV, the otoconia are dislodged from their usual position within the utricle and they migrate over time into one of the semicircular canals (the posterior canal is most commonly affected due to its anatomical position). When the head is reoriented relative to gravity, the gravity-dependent movement of the heavier otoconial debris within the affected semicircular canal causes abnormal (pathological) fluid endolymph displacement and a resultant sensation of vertigo. This more common condition is known as canalithiasis.
In rare cases, the crystals themselves can adhere to a semicircular canal cupula rendering it heavier than the surrounding endolymph. Upon reorientation of the head relative to gravity, the cupula is weighted down by the dense particles thereby inducing an immediate and maintained excitation of semicircular canal afferents afferent nerve. This condition is termed cupulolithiasis.
It can be triggered by any action which stimulates the posterior semi-circular canal which may be:
- Tilting the head
- Rolling over in bed
- Looking up or under
- Sudden head motion
BPPV may be made worse by any number of modifiers which may vary between individuals:
- Changes in barometric pressure - patients often feel symptoms approximately two days before rain or snow
- Lack of sleep (required amount of sleep may vary widely)
- Stress
Signs and symptoms
- Symptoms(Things you might feel):
- Vertigo: Spinning dizziness which is not light headed or off balance.
- Short duration (Paroxysmal): Lasts only seconds to minutes
- Positional in onset: Only can be induced by a change in position.
- Nausea is often associated
- Visual disturbance: It may be difficult to read or see during an attack due to the associated nystagmus.
- Signs (Things someone might observe about you):
- Rotatory (torsional) nystagmus, where the top of the eye rotates towards the affected ear and a beating or twitching fashion.
- Emesis (Vomiting) is uncommon but possible.
- Pre-Syncope (feeling faint) or Syncope (fainting) is unusual.
Patients do not experience other neurological deficits such as numbness or weakness, and if these symptoms are present, a more concerning etiology such as posterior circulation stroke, must be considered.
Diagnosis
The condition is diagnosed from patient history (feeling of vertigo with sudden changes in positions); and by performing the Dix-Hallpike maneuver which is diagnostic for the condition. The test involves a reorientation of the head to align the posterior canal (at its entrance to the ampulla) with the direction of gravity. This test stimulus is effective in provoking the symptoms in subjects suffering from archetypal BPPV. These symptoms are typically a short lived vertigo, and observed nystagmus. In some patients, the vertigo can persist for years.
Treatment
The treatment of choice for this condition is the Epley canalith repositional maneuver which is effective in approximately 80% of patients[2]. The treatment employs gravity to move the calcium build-up that causes the condition.[3] The particle repositioning maneuver (Epley's maneuver) can be performed during a clinic visit by specially trained otolaryngologists, neurologists, chiropractors, physical therapists, or audiologists. The maneuver is relatively simple but few general health practitioners know how to perform it. A method known as the Semont maneuver[4] in which patients themselves are able to achieve canalith repositioning has been shown to be effective.[5]
Devices such as a head over heels "rotational chair" are available at some tertiary care centers [6] Home devices, like the DizzyFIX, are also available for the treatment of BPPV and vertigo. [7][8]
The Epley maneuver (particle repositioning) does not address the actual presence of the particles (otoconia), rather it changes their location. The maneuver moves these particles from areas in the inner ear which cause symptoms, such as vertigo, and repositions them into areas where they do not cause these problems.
Meclizine is a commonly prescribed medication, but is ultimately ineffective for this condition, other than masking the dizziness. Other sedative medications help mask the symptoms associated with BPPV but do not affect the disease process or resolution rate. Betahistine (trade name Serc) is available in some countries and is commonly prescribed but again it is likely ineffective. Particle repositioning remains the current gold standard treatment for most cases of BPPV.
Surgical treatments, such as a semi-circular canal occlusion, do exist for BPPV but carry the same risk as any neurosurgical procedure. Surgery is reserved for severe and persistent cases which fail particle repositioning and medical therapy.
Famous sufferers
See also
References
- ^ a b Bhattacharyya N, Baugh RF, Orvidas L; et al. (2008). "Clinical practice guideline: benign paroxysmal positional vertigo" (PDF). Otolaryngol Head Neck Surg. 139 (5 Suppl 4): S47–81. doi:10.1016/j.otohns.2008.08.022. PMID 18973840.
{{cite journal}}: Explicit use of et al. in:|author=(help); Unknown parameter|laydate=ignored (help); Unknown parameter|laysource=ignored (help); Unknown parameter|laysummary=ignored (help)CS1 maint: multiple names: authors list (link) - ^ BPPV on Dizziness-and-Balance.com
- ^ von Brevern M, Seelig T, Radtke A; et al. (2006). "Short-term efficacy of Epley's maneuver: a double-blind randomised trial". J Neurol Neurosurg Psychiatr. 77: 980–82. doi:10.1136/jnnp.2005.085894. PMID 16549410.
{{cite journal}}: Explicit use of et al. in:|author=(help)CS1 maint: multiple names: authors list (link) - ^ American Academy of Neurology, Self-treatment of benign paroxysmal positional vertigo
- ^ Radtke A, von Brevern M, Tiel-Wilck K, Mainz-Perchalla A, Neuhauser H, Lempert T. (2004). "Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure". Neurology. 63(1).
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Furman JM, Cass SP, Briggs BC. (1998). "Treatment of benign positional vertigo
using heels-over-head rotation". Ann Otol Rhinol Laryngol. 107:: 1046–53.
{{cite journal}}: line feed character in|title=at position 39 (help)CS1 maint: extra punctuation (link) CS1 maint: multiple names: authors list (link) - ^ Beyea J, Wong E, Bromwich M, Weston W, Fung K. (2007). "Evaluation of a Particle Repositioning Maneuver Web-Based Teaching Module Using the DizzyFIX". Laryngoscope. 117:.
{{cite journal}}: CS1 maint: extra punctuation (link) CS1 maint: multiple names: authors list (link) - ^ Bromwich MA, Parnes LS. (2008). "The DizzyFix: Initial Results of a New Dynamic Visual Device for the Home Treatment of Benign Paroxysmal Positional Vertigo". J Otolaryngol. 37(3):.
{{cite journal}}: CS1 maint: extra punctuation (link)
External links
- NHSdirect NHSdirect.nhs.co.uk
- VEDA Vestibular Disorder Association webpage concerning BPPV
- MayoClinic
- Dizzytimes.com Online Community for Sufferers of Vertigo and Dizziness
Great summary and picturgraphs of treatment positions.