Benign paroxysmalpositional vertigo(BPPV)
Symptoms, diagnosis, and treatment
Benign paroxysmal positional vertigo (BPPV) is a feeling of vertigo which occurs due to a change in position. The word “benign” means harmless, while “paroxysmal” means spasmodic. In some cases, the designation “peripheral paroxysmal positional vertigo” (PPPV) is used, meaning the same kind of dizziness (vertigo in Latin and English). In this connection, peripheral means involving an outer area of the body.
In principle, BPPV is harmless, but it is nevertheless unpleasant for those who experience it daily. Doctors believe that a detachment of the otoliths (also known as ear stones or statoliths) from the macular organs (macula – small area in the vestibule), the utricle and the saccule.
These ear stones then find their way into the vestibules of the balance organs, causing the dizziness. You will find more information about the causes, symptoms, and treatment of BPPV in the following sections below.
The symptoms of BPPV
There are different symptoms which are characteristic of BPPV:
- Turning over in bed
- Sitting up from a position lying down
- Bending over quickly
- Turning onto the affected side
It can also involve a so-called rotary vertigo, which usually occurs when the head changes position very quickly. This rotary dizziness is often referred to as a carousel in the head (carousel dizziness). It can occur in the following situations:
- Occasional occurrence (paroxysmal)
- Occurrence depends on position
- Duration of a few seconds
- Ends on its own
If the positional vertigo occurs while lying down and turning from one side to the other, cardiovascular causes can be excluded as a rule. Other forms of dizziness occur most frequently due to disorders of the inner ear, the eyes, or the brain.
Treatment: exercises to help with BPPV
BBPV cannot be treated with medication, because, according to current knowledge, it would have no effect. Instead, positional exercises have been developed, which help the detached particles return to the otolith organs (utricle and saccule). There are different types, or forms, of positional vertigo. The most common are anterior (farther forward) and posterior (farther back) forms, which indicate either the anterior or posterior canals. The vertigo can usually be relieved with the appropriate exercises. Both types can be treated with the Sémont or the Epley maneuvers.
For this maneuver, the patient sits upright in front of the physician, head turned 45° to show the affected side to the doctor. Then the patient abruptly lies down on the affected side, head remaining in the same position. Now the patient is lying sideways on the examining table and looking upward. He maintains this position for 2-3 minutes, then turns over 180° onto his other side, keeping his head in the same position, so that now he’s looking in the direction of the table. Then the patient is slowly returned to his initial position and stays there for 3 minutes.
Short tutorial for the Sémont maneuver in three easy steps: 1. Sitting upright; 2. Body tilts onto one shoulder; 3. Rapid 180° turn onto the other shoulder; customize maneuver as needed for right or left ear.
This maneuver was created by Dr. John Epley in 1980. The patient sits upright, legs outstretched, in front of the physician. The head is turned 45° to the affected side, so the physician is looking at the good ear. Then the patient changes rapidly to a supine position so that the head hangs over the edge of the examination table. The patient must remain in this position until the vertigo and nystagmus have receded (at least 1 minute). Then the patient turns onto the healthy side, keeping his head in the same position, and waits approximately another minute. The last step in this maneuver is sitting upright again. The patient should keep his eyes closed to avoid any vertigo-induced nausea during this maneuver.
If the patient does not respond to this treatment, positional training, according to Brandt and Daroff, is recommended. During these exercises, the patient changes position alternately to the right and the left. He remains in one position for about 30 seconds, and he sits upright again in between the positions.
Directions for the Epley maneuver in 5 steps: 1. Sitting upright, head turned 45° to the right; 2. Lying down; 3. Head turned 90° to the left; 4. Whole body turned 90° to the left; 5. Sitting up with head tipped slightly to the left; repeat the maneuver mirrored for the left ear.
Origin and causes of BPPV
Generally, benign positional vertigo is accompanied by detachment of the ear stones, which then arrive in the semicircular canals, thus travelling into the new deepest point. The canal liquid moves, leading to deviation in the cupula (gelatinous cone in the posterior canal) and irritating the affected canal. There are different causes of the ear stone detachment:
- Inflammation of the balance organs in the inner ear
- Previous motor vehicle and sports accidents
- Head trauma or injury
- Advanced age
In the case of disturbances or balance organ failure, the possibility exists that spatial information is being transmitted to the brain incorrectly, typically resulting in rotary vertigo. The precise cause of otolith detachment is s till unknown.