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Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is one of the causes of vertigo (dizziness). Find out what causes it, its symptoms, how it’s treated and more below.

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About The Disease

Benign Paroxysmal Positional Vertigo (BPPV) is one of the commonest causes of vertigo. These patients usually complain of sudden spinning on getting up from bed or changing position. It lasts from few to several seconds. This is caused by displacement of calcium carbonate particles into the semicircular canals in the inner ear. On going to certain positions, theses particles stimulate the balance nerve leading to a feeling of spinning.

Causes of BPPV

Some conditions can predispose to BPPV like:

  • Head injury
  • Bed rest – prolonged
  • Old age
  • Ear infection
  • Ear surgery

However in most patients of BPPV, no known cause is apparent. These are called Primary or Idiopathic BPPV.

Symptoms : BPPV patients may complain of

  • Dizziness
  • Spinning – brought on by a change of position
  • Unsteadiness or Imbalance
  • Nausea or vomiting

Episodes of spinning usually last less than one minute. Some people also feel off-balance when they are standing or walking.

Diagnosis

In BPPV, moving to certain positions lead to stimulation of the balance nerve. This leads to the generation of jerky eye movements called nystagmus. Nystagmus does not allow the patient to keep their eyes steady and they feel a spinning sensation.

Tests like the Dix-Hallpike or Roll Tests involve moving the head into specific positions, which makes the dislodged crystals migrate due to gravity and trigger vertigo while the doctor watches for the revealing eye movements or nystagmus. These tests when done under VNG guided magnification and recording allow an exact diagnosis of the position of the otolith particles. After ascertaining the position of the crystals, the manoeuvre required to remove the crystals would be decided.

Dix-Hallpike Manoeuvre

The doctor will conduct a Dix-Hallpike test by taking the patient on the examination couch, turning head by 45° and then taking going to the head hanging position by 30° down. Any involuntary eye movements indicate the presence of BPPV in the posterior semicircular canal of that side.

Other tests like the Supine Roll test are done to check if there are otoliths in the lateral semicircular canals. The deep head hanging test is done to check for anterior canal BPPV.

Types of BPPV

There are two kinds of BPPV: Canalithiasis and Cupulolithiasis.

In Canalithiasis, the loose Calcium Carbonate particles can move freely in the fluid of the canal. Their movement stimulates the balance nerve resulting in vertigo.

On the other hand, Cupulolithiasis is a less common condition in which the crystals get stuck on the cupula (the sensory organ) causing more intense and longer spells of vertigo.

MRI does not help in the diagnosis of BPPV.

Treatment of BPPV

1. Canalith Repositioning :

As BPPV is a physical disorder caused by displacement of otoconial debris, the mainstay of treatment involves a repositioning of these particles back to their original position. Various manoeuvre have been described for treatment of BPPV. a few common manoeuvre are

  • Eply’s Manoeuvre
  • Semont’s Manoeuvre
  • Barbeque manoeuvre
  • Gufoni Manoeuvre

A correctly done manoeuvre can provide relief to most patients of BPPV.

2. BPPV Exercises

BPPV can be corrected by different repositioning manoeuvres depending on the position of the particles. Once your health care provider diagnoses which canal or canals the crystals are in and what type of BPPV it is (Canalithiasis or Cupulolithiasis), then they can perform the suitable manoeuvre to treat you.

The manoeuvres use gravity to guide the crystals back into the utricle via a particular sequence of head positioning called Canalith/Particle Repositioning Manoeuvres.

In the case of Cupulolithiasis, quick head movement at the level of the affected canal is used to dislodge the ‘hung-up’ crystals, called a Liberatory Manoeuvre.

Epley’s manoeuvre is one of the most commonly used manoeuvres to treat BPPV. However, that does not work for all types of BPPV.

Often people try the Epley’s manoeuvre themselves or have it performed on them by a practitioner, without seeing any success. Later, assessments reveal that a different manoeuvre should have been used, instead of Epley Manoeuvre as the otolith was stuck in a different canal. Or sometimes, the condition may have been wrongly diagnosed as BPPV, where in reality, it is not BPPV at all!

Other manoeuvres used for canalith repositioning include the Semont’s manoeuvre, Gufoni manoeuvre, Vanucchi manoeuvre, deep head hanging, reverse Epley, Yacovino etc. These manoeuvres are recommended for different kinds of BPPV. That is why doctors urge caution while using self-treatment or being treated by someone who is not trained in identifying and treating different variants of BPPV.

Brandt – Daroff exercises may be beneficial as a home exercise for patients who do not respond well often particle repositioning manoeuvres or have multiple recurrences. However, these exercises must be done with caution as the patient may experience vertigo while doing them.

3. Canalith Repositioning

According to the position of the particle, different manoeuvres help in repositioning the sialoliths in the ear to reduce vertigo. The repositioning if correctly done can treat the patient on the table without medication.

4. Epley Manoeuvre

This exercise is the most commonly used to treat BPPV. When an experienced doctor conducts the Epley manoeuvre on a BPPV patient, it can bring about almost instantaneous results. At NeuroEquilibrium™, the trained professionals assist the BPPV patients with Epley manoeuvre done under VNG-guidance.

How To Do Epley Manoeuvre?

The steps below describe the manoeuvre for BPPV of the right posterior semicircular canal.

Step 1: First, you sit on the table with your legs stretched straight in front of you.

Step 2: The clinician will turn your head to the right at 45 degrees.

Step 3: The clinician will then swifty lower your head 300 degrees into a hanging position.

Step 4: This position should be held for about 30 seconds or until vertigo ceases.

Step 5: Now, the head is turned to the opposite side, so that it is 45 degrees to the left.

Step 6: Hold this position for 30 more seconds or until vertigo ceases.

Step 7: Patient is turned further to the left side and kept there for 30 seconds more.Keep in mind that you should not turn to the side which has vertigo problem.

Step 8: Patient is then made to sit up fast.

The doctor will help to manoeuvre your head swiftly from one side to another so that the canaliths move back to their correct position.

5. Semont Manoeuvre

This repositioning exercise is best done assisted by a trained doctor. Similar to the Epley manoeuvre, Semont’s manoeuvre helps the otoliths to be liberated and repositioned to their correct position.

How To Do Semont Manoeuvre?

Step 1: The patient is made you sit on the table with legs down.

Step 2: If the problem is on the left side, the doctor will turn your head to the right at 45 degrees. Vice-versa if you have a problem on your right side.

Step 3: Holding your head at 45 degrees to your right, you will be made to go down on your left side, with your nose facing up.

Step 4: This position is held for 30 seconds.

Step 5: Now, holding your head in the same direction, you will be swiftly swung to the opposite side. In this position, your nose will be pointing down at the table.

Step 6: Hold this position for 30 more seconds.

Step 7: You will be helped to sit back gently on the table until you feel fit to stand up.

Epley and Semont manoeuvres are very efficient in treating BPPV. This makes them popular and the first choice of treatment for BPPV.

6. Barbeque Manoeuvre

This manoeuvre is used for patients suffering from BPPV of the lateral semicircular canals.

7. Brandt-Dariff Exercise

This exercise helps the brain cope with the confusing signals it receives, as a result of inner ear problems. Brandt-Daroff exercise is done two-three times daily, for several weeks to get the desired results.

How To Do Brandt-Daroff Exercise?

Step 1: Sit straight on the bed with your legs down.

Step 2: Turn the head 45 degrees to your left. Take the body down to the right so that the head is on the bed and nose facing upwards.

Step 3: This position is to be held for 30 seconds or until your vertigo symptoms subside.

Step 4: Sit back as in step 1.

Step 5: Now turn your head 45 degrees to your right and take the body to the left with the nose facing upwards.

Step 6: Hold this position for 30 more seconds.

Step 7: Get up and sit on the bed.

These steps are repeated 3 times twice a day. The exercise should be done in the presence of an attendant to support the patient if the Vertigo is strong.

Surgery

Surgery is indicated in rare cases where the liberatory manoeuvres are not effective or multiple recurrences affect the day to day life of the patient. Some of the types of surgeries that can be performed to treat BPPV are singular neurectomy, and canal occlusion or plugging.

Dr. Anita Bhandari

Dr.Anita Bhandari is MS(ENT) and a consultant Neurotologist practising in Jaipur, India. She has done a fellowship in Otology and Neurotology from Singapore. She has set up a state-of-art Vertigo and Ear Clinic in Jaipur (www.vertigoandearclinic.com) which is amongst the most advanced vertigo clinics in India. Dr. Bhandari is actively involved in the development of diagnostic equipment in the field of diagnosis and rehabilitation of vertigo and balance disorders. She has contributed to the development of Computerised Dynamic Visual Acuity, Cranio-Corpography, Subjective Visual Vertical, Video Nystagmography and Posturography diagnostic equipment and has two patents in this field. She has also been involved in the development of Virtual reality for vestibular rehabilitation. She is Scientific advisor to NeuroEquilibrium™, a unique project to set up 500 super-specialised vertigo and dizziness clinics in India, Asia & Africa leveraging cloud technology. She has authored chapters on ‘Vestibular Physiology’, ‘Dynamic Visual Acuity’, ‘Surgical treatment of vertigo’, ‘Difficult cases in vertigo’ in various Neurotology textbooks. She is an invited speaker in various Vertigo & Neurotology conferences across the world. Dr.Anita Bhandari is MS(ENT) and a consultant Neurotologist practising in Jaipur, India. She has done a fellowship in Otology and Neurotology from Singapore. She has set up a state-of-art Vertigo and Ear Clinic in Jaipur (www.vertigoandearclinic.com) which is amongst the most advanced vertigo clinics in India. Dr. Bhandari is actively involved in the development of diagnostic equipment in the field of diagnosis and rehabilitation of vertigo and balance disorders. She has contributed to the development of Computerised Dynamic Visual Acuity, Cranio-Corpography, Subjective Visual Vertical, Video Nystagmography and Posturography diagnostic equipment and has two patents in this field. She has also been involved in the development of Virtual reality for vestibular rehabilitation. She is Scientific advisor to NeuroEquilibrium™, a unique project to set up 500 super-specialised vertigo and dizziness clinics in India, Asia & Africa leveraging cloud technology. She has authored chapters on ‘Vestibular Physiology’, ‘Dynamic Visual Acuity’, ‘Surgical treatment of vertigo’, ‘Difficult cases in vertigo’ in various Neurotology textbooks. She is an invited speaker in various Vertigo & Neurotology conferences across the world.

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