Benign Paroxysmal Positional Vertigo (BPPV)

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.

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.

• 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.

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.

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.

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. 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 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.