About The Disease
One of the most prevalent causes of vertigo is Benign paroxysmal positional vertigo (BPPV). It is an inner ear problem and presents with the symptom of a sudden sensation of spinning on change of position or while turning in bed. It occurs when calcium carbonate particles (otoconia) that are typically embedded in the gel in the utricle become displaced and migrate into one or more of the three fluid-filled semicircular canals. When these otoliths accumulate in one of the canals in the inner ear, they meddle with the natural fluid movement that these canals use to sense head motion, causing the inner ear to send false signals to the brain.
The spinning sensation or vertigo lasts less than a minute. Between vertigo spells, some people feel no symptoms, while others feel a mild sense of imbalance or disequilibrium.
Causes Of BPPV
Some conditions can predispose to causing BPPV like:
- Head injury
- Bed rest – prolonged
- Old age
- Ear infection
- Ear surgery
Signs And Symptoms of BPPV
However, some people may develop this condition without any apparent cause. This is called idiopathic.
The symptoms of benign paroxysmal positional vertigo may include:
- A feeling that your surroundings are spinning (vertigo) – brought on by a change of position
- Unsteadiness or Imbalance
Episodes of spinning usually last less than one minute. Episodes of benign paroxysmal positional vertigo can disappear for some time and then recur.
It has been observed that the symptoms are triggered when the person changes his head position. Some people also feel off-balance when they are standing or walking.
Abnormal rhythmic eye movements, called nystagmus usually accompany the symptoms of benign paroxysmal positional vertigo.
When someone with BPPV moves their head into a particular position that makes the dislodged crystals stimulate balance nerve fibres, the wrong signals cause the eyes to move in a very distinct pattern, referred to as “nystagmus”.
The connection between the inner ears and the eye muscles allow us to stay focused on our environment while the head is moving. This is called the Vestibulo-ocular reflex (VOR). The stimulation by the dislodged crystals causes the sensation of movement and generation of nystagmus. The nystagmus will have different characteristics according to the placement of the displaced crystals within the semi-circular canals.
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.
The doctor will conduct a Dix-Hallpike test to evaluate for BPPV. The Dix-Hallpike examination is done by taking the patient on the examination couch, turning head by 45° and then taking the patient 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 McClure 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 crystals can move freely in the fluid of the canal.
On the other hand, Cupulolithiasis is a less common pattern of otolith dislodgement. In this condition, the crystals get stuck on the cupula causing more intense and longer spells of vertigo. .In canalithiasis, it takes less than a minute for the crystals to stop moving after the head position is changed to a particular angle that has triggered vertigo. Once the calcium carbonate crystals stop moving the fluid will settle. Subsequently, nystagmus and vertigo stop too.
In cupulolithiasis, the crystals attached to the bundle of sensory nerves cause the nystagmus, and vertigo lasts longer often until the head is moved out of the offending position. It is important to make this distinction, as the treatment is different for each variant.
MRI does not help in the diagnosis of BPPV.
Treatment of BPPV
Medication like vestibular suppressants does not help in BPPV. They are meant to suppress the sensation of Vertigo rather than treat the BPPV.
If the cause of BPPV is ear infection or inflammation, the doctor would prescribe antibiotics and other medications. The doctor may suggest antiemetics to treat acute nausea and vomiting associated with severe vertigo cases.
Medicines do not help in the treatment of BPPV. Surgical treatment is required only in very rare cases where Maneuvres are not effective or recurrence becomes common.
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 he can take you for the suitable manoeuvre.
The manoeuvres use gravity to guide the crystals back into the utricle via a particular sequence of head positioning called Canalith/Particle Repositioning Maneuvers.
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 Maneuver.
Epley’s manoeuvre is one of the most commonly used manoeuvres to treat BPPV. However, that will 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 it is a different manoeuvre that should have been used, instead of Epley Maneuver 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, Yacovini etc. These maneuvres 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 maneuvres or have multiple recurrences. However, these exercises must be done with caution as the patient may experience vertigo while doing them.
- Canalith Repositioning: According to the position of the particle, different maneuvres 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.
- Epley Maneuver: 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 Maneuver?
The steps below describe the Maneuvre 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 therapist will turn your head to the right at 45 degrees.
Step 3: The therapist will then take you to the head swiftly hanging position 300 lower.
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 Turn to the left side and kept there for 30 seconds more. Note 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.
- Sermont Maneuver: 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 Maneuver?
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 to treat BPPV. That makes them popular and the first choice of treatment for BPPV.
- Barbeque Maneuver: This manoeuvre is used for patients suffering from BPPV of the lateral semicircular canals.
- 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 is indicated in rare cases where the liberatory maneuvres 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.
Emergency Medical Treatment
In the general scenario, the symptoms of BPPV are not severe. If they are severe, you should seek medical attention immediately.
Emergency Conditions Requiring Immediate Medical Help:
- Difficulty in breathing
- Difficulty in focusing
- paralysis in any part of the body
- Feeling numb or weak in any part of the body
- Feeling disoriented
- An unbearable headache
- Incessant vomiting
- Loss of hearing
- Chest pain
NeuroEquilibrium has sophisticated devices to diagnose BPPV and offer customised medical treatments for patients suffering from vertigo and balance disorder issues.
Author: Dr. Anita Bhandari
Dr.Anita Bhandari is MS(ENT) and a consultant Neurotologist practicing 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 development of diagnostic equipment in the field of diagnosis and rehabilitation of vertigo and balance disorders. She has contributed to the development of Computerized Dynamic Visual Acuity , Cranio-Coprpography , Subjective Visual Vertical , Video Nystagmography and
Posturography diagnostic equipment and has two patents in this field . She has also been involved in development of Virtual reality for vestibular rehabilitation . She is Scientific advisor to NeuroEquilibrium, a unique project to set up 500 super-specialized 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.