Benign paroxysmal positional vertigo (BPPV) is a disorder arising from a problem in the
inner ear
The inner ear (internal ear, auris interna) is the innermost part of the vertebrate ear. In vertebrates, the inner ear is mainly responsible for sound detection and balance. In mammals, it consists of the bony labyrinth, a hollow cavity in the ...
.
Symptoms are repeated, brief periods of
vertigo
Vertigo is a condition where a person has the sensation of movement or of surrounding objects moving when they are not. Often it feels like a spinning or swaying movement. This may be associated with nausea, vomiting, sweating, or difficulties w ...
with movement, characterized by a spinning sensation upon changes in the position of the head.
[
* ] This can occur with turning in bed or changing position.
[ Each episode of vertigo typically lasts less than one minute.][ ]Nausea
Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the ...
is commonly associated.[ BPPV is one of the most common causes of vertigo.]
BPPV is a type of balance disorder
A balance disorder is a disturbance that causes an individual to feel unsteady, for example when standing or walking. It may be accompanied by feelings of giddiness, or wooziness, or having a sensation of movement, spinning, or floating. Balance ...
along with labyrinthitis
Labyrinthitis is inflammation of the labyrinth – a maze of fluid-filled channels in the inner ear. Vestibular neuritis is inflammation of the vestibular nerve – the nerve in the inner ear that sends messages related to motion and position t ...
and Ménière's disease
Ménière's disease (MD) is a disease of the inner ear that is characterized by potentially severe and incapacitating episodes of vertigo, tinnitus, hearing loss, and a feeling of fullness in the ear. Typically, only one ear is affected initial ...
.[ It can result from a ]head injury
A head injury is any injury that results in trauma to the skull or brain. The terms ''traumatic brain injury'' and ''head injury'' are often used interchangeably in the medical literature. Because head injuries cover such a broad scope of inju ...
or simply occur among those who are older.[ Often, a specific cause is not identified.][ When found, the underlying mechanism typically involves a small calcified ]otolith
An otolith ( grc-gre, ὠτο-, ' ear + , ', a stone), also called statoconium or otoconium or statolith, is a calcium carbonate structure in the saccule or utricle of the inner ear, specifically in the vestibular system of vertebrates. The sa ...
moving around loose in the inner ear.[ Diagnosis is typically made when the ]Dix–Hallpike test
The Dix–Hallpike test — or Nylén–Bárány test — is a diagnostic maneuver from the group of rotation tests used to identify benign paroxysmal positional vertigo (BPPV).
Procedure
When performing the Dix–Hallpike test, patients are lowe ...
results in nystagmus
Nystagmus is a condition of involuntary (or voluntary, in some cases) eye movement. Infants can be born with it but more commonly acquire it in infancy or later in life. In many cases it may result in reduced or limited vision. Due to the invol ...
(a specific movement pattern of the eyes) and other possible causes have been ruled out.[ In typical cases, ]medical imaging
Medical imaging is the technique and process of imaging the interior of a body for clinical analysis and medical intervention, as well as visual representation of the function of some organs or tissues (physiology). Medical imaging seeks to rev ...
is not needed.[
BPPV is easily treated with a number of simple movements such as the ]Epley maneuver
The Epley maneuver or repositioning maneuver is a maneuver used by medical professionals to treat one common cause of vertigo, benign paroxysmal positional vertigo (BPPV) of the posterior or anterior canals of the ear. The maneuver works by all ...
( in case of diagonal/rotational nystagmus ), the Lempert maneuver ( in case of horizontal nystagmus ), the deep head hanging maneuver ( in case of vertical nystagmus ) or sometimes the less effective Brandt–Daroff exercises
Benign paroxysmal positional vertigo (BPPV) is a disorder arising from a problem in the inner ear. Symptoms are repeated, brief periods of vertigo with movement, characterized by a spinning sensation upon changes in the position of the head.
* ...
. Medications, including antihistamine
Antihistamines are drugs which treat allergic rhinitis, common cold, influenza, and other allergies. Typically, people take antihistamines as an inexpensive, generic (not patented) drug that can be bought without a prescription and provides re ...
s such as meclizine
Meclizine, sold under the brand name Bonine, among others, is an antihistamine used to treat motion sickness and dizziness (vertigo). It is taken by mouth. Effects generally begin in an hour and last for up to a day.
Common side effects incl ...
, may be used to help with nausea
Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the ...
.[ There is tentative evidence that ]betahistine
Betahistine, sold under the brand name Serc among others, is an anti-vertigo medication. It is commonly prescribed for balance disorders or to alleviate vertigo symptoms. It was first registered in Europe in 1970 for the treatment of Ménière ...
may help with vertigo, but its use is not generally needed.[ BPPV is not a serious medical condition,][ but may present serious risks of injury through falling or other spatial disorientation-induced accidents.
When untreated, it might resolve in days to months;] however, it may recur in some people. One can needlessly suffer from BPPV for years despite there being a simple an very effective cure. Short-term self-resolution of BPPV is unlikely because the effective cure maneuvers induce strong vertigo which the patient will naturally resist and not accidentally perform.
The first medical description of the condition occurred in 1921 by Róbert Bárány. Approximately 2.4% of people are affected at some point in time.[ Among those who live until their 80s, 10% have been affected.][ BPPV affects females twice as often as males.][ Onset is typically in people between the ages of 50 and 70.][
]
Signs and symptoms
Symptoms:
* Paroxysmal
Paroxysmal attacks or paroxysms (from Greek παροξυσμός) are a sudden recurrence or intensification of symptoms, such as a spasm or seizure. These short, frequent symptoms can be observed in various clinical conditions. They are usuall ...
—appears suddenly, and in episodes of short duration: lasts only seconds to minutes
* Positional—is induced by a change in position, even slight
* Vertigo
Vertigo is a condition where a person has the sensation of movement or of surrounding objects moving when they are not. Often it feels like a spinning or swaying movement. This may be associated with nausea, vomiting, sweating, or difficulties w ...
—a spinning dizziness, which must have a rotational component
* Torsional nystagmus
Nystagmus is a condition of involuntary (or voluntary, in some cases) eye movement. Infants can be born with it but more commonly acquire it in infancy or later in life. In many cases it may result in reduced or limited vision. Due to the invol ...
—a diagnostic symptom where the top of the eye rotates toward the affected ear in a beating or twitching fashion, which has a latency and can be fatigued (vertigo should lessen with deliberate repetition of the provoking maneuver): nystagmus should only last for 30 seconds to one minute
* Pre-syncope
Lightheadedness is a common and typically unpleasant sensation of dizziness or a feeling that one may faint. The sensation of lightheadedness can be short-lived, prolonged, or, rarely, recurring. In addition to dizziness, the individual may feel ...
—(feeling faint) or syncope (fainting) is unusual, but possible
* Visual disturbance—due to associated nystagmus
Nystagmus is a condition of involuntary (or voluntary, in some cases) eye movement. Infants can be born with it but more commonly acquire it in infancy or later in life. In many cases it may result in reduced or limited vision. Due to the invol ...
, making it difficult to read or see during an attack
* Nausea
Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. While not painful, it can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the ...
—is often associated
* Vomiting
Vomiting (also known as emesis and throwing up) is the involuntary, forceful expulsion of the contents of one's stomach through the mouth and sometimes the Human nose, nose.
Vomiting can be the result of ailments like Food-poisoning, foo ...
—is common, depending on the strength of vertigo itself and the causes for this illness
Many people will report a history of vertigo as a result of fast head movements. Many are also capable of describing the exact head movements that provoke their vertigo. Purely horizontal nystagmus and symptoms of vertigo lasting more than one minute can also indicate BPPV occurring in the horizontal semicircular canal.
The spinning sensation experienced from BPPV is usually triggered by movement of the head, will have a sudden onset, and can last anywhere from a few seconds to several minutes. The most common movements people report triggering a spinning sensation are tilting their heads upward in order to look at something and when rolling over in bed.
People with BPPV do not experience other neurological deficits such as numbness
Hypoesthesia or numbness is a common side effect of various medical conditions that manifests as a reduced sense of touch or sensation, or a partial loss of sensitivity to sensory stimuli. In everyday speech this is generally referred to as num ...
or weakness
Weakness is a symptom of a number of different conditions. The causes are many and can be divided into conditions that have true or perceived muscle weakness. True muscle weakness is a primary symptom of a variety of skeletal muscle diseases, i ...
. If those symptoms are present, a more serious etiology, such as posterior circulation stroke
A stroke is a medical condition in which poor blood flow to the brain causes cell death. There are two main types of stroke: ischemic, due to lack of blood flow, and hemorrhagic, due to bleeding. Both cause parts of the brain to stop functionin ...
or ischemia, must be considered.
The most significant symptom is nystagmus as it is essential to determine the kind of nystagmus ( horizontal, vertical, or diagonal ) to select the correct cure maneuver.
Cause
Within the labyrinth
In Greek mythology, the Labyrinth (, ) was an elaborate, confusing structure designed and built by the legendary artificer Daedalus for King Minos of Crete at Knossos. Its function was to hold the Minotaur, the monster eventually killed by the ...
of the inner ear
The inner ear (internal ear, auris interna) is the innermost part of the vertebrate ear. In vertebrates, the inner ear is mainly responsible for sound detection and balance. In mammals, it consists of the bony labyrinth, a hollow cavity in the ...
lie collections of calcium crystals known as otoconia or otoliths. In people with BPPV, the otoconia are dislodged from their usual position within the utricle, and over time, migrate into one of the three semicircular canals
The semicircular canals or semicircular ducts are three semicircular, interconnected tubes located in the innermost part of each ear, the inner ear. The three canals are the horizontal, superior and posterior semicircular canals.
Structure
The ...
(the posterior canal
The semicircular canals or semicircular ducts are three semicircular, interconnected tubes located in the innermost part of each ear, the inner ear. The three canals are the horizontal, superior and posterior semicircular canals.
Structure
The ...
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 (colloquially "ear rocks") within the affected semicircular canal causes abnormal (pathological) endolymph
Endolymph is the fluid contained in the membranous labyrinth of the inner ear. The major cation in endolymph is potassium, with the values of sodium and potassium concentration in the endolymph being 0.91 mM and 154 mM, respectively. I ...
fluid displacement and a resultant sensation of vertigo
Vertigo is a condition where a person has the sensation of movement or of surrounding objects moving when they are not. Often it feels like a spinning or swaying movement. This may be associated with nausea, vomiting, sweating, or difficulties w ...
. This more common condition is known as ''canalithiasis''. There is a direct link between the kind of nystagmus and which of the three semicircular canals is affected. With horizontal nystagmus ( left-right eye movement ) the horizontal ( also called lateral ) canal is affected, with vertical nystagmus ( up-down eye movement ) the superior ( also called anterior ) canal is affected, and with diagonal nystagmus ( diagonal or rotational eye movement ) the posterior canal is affected. Diagonal eye movement is easily confused with horizontal movement. This is important since it might result in selecting a wrong and thus ineffective cure maneuver.
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 sustained excitation of semicircular canal afferent nerve
A sensory nerve, or afferent nerve, is a general anatomic term for a nerve which contains predominantly somatic afferent nerve fibers. Afferent nerve fibers in a sensory nerve carry sensory information toward the central nervous system (CNS) fro ...
s. This condition is termed ''cupulolithiasis''.
There is evidence in the dental literature that malleting of an osteotome
An osteotome is an instrument used for cutting or preparing bone. Osteotomes are similar to a chisel but bevelled on both sides. They are used today in plastic surgery, orthopedic surgery and dental implantation.
The chain osteotome, original ...
during closed sinus floor elevation, otherwise known as ''osteotome sinus elevation'' or ''lift'', transmits percussive and vibratory forces capable of detaching otoliths from their normal location and thereby leading to the symptoms of BPPV.
BPPV can be triggered by any action that stimulates the posterior semi-circular canal including:
* Looking up or down
* Following head injury
A head injury is any injury that results in trauma to the skull or brain. The terms ''traumatic brain injury'' and ''head injury'' are often used interchangeably in the medical literature. Because head injuries cover such a broad scope of inju ...
* Sudden head movement
* Rolling over in bed
* Tilting the head
BPPV may be made worse by any number of modifiers which may vary among individuals:
* Changes in barometric pressure
Atmospheric pressure, also known as barometric pressure (after the barometer), is the pressure within the atmosphere of Earth. The standard atmosphere (symbol: atm) is a unit of pressure defined as , which is equivalent to 1013.25 millibars, 7 ...
– people may feel increased symptoms up to two days before rain or snow
* Lack of sleep (required amounts of sleep
Sleep is a sedentary state of mind and body. It is characterized by altered consciousness, relatively inhibited sensory activity, reduced muscle activity and reduced interactions with surroundings. It is distinguished from wakefulness by a de ...
may vary widely)
* Stress
Stress may refer to:
Science and medicine
* Stress (biology), an organism's response to a stressor such as an environmental condition
* Stress (linguistics), relative emphasis or prominence given to a syllable in a word, or to a word in a phrase ...
An episode of BPPV may be triggered by dehydration, such as that caused by diarrhea
Diarrhea, also spelled diarrhoea, is the condition of having at least three loose, liquid, or watery bowel movements each day. It often lasts for a few days and can result in dehydration due to fluid loss. Signs of dehydration often begin wi ...
. For this reason, it commonly occurs in people with post-operative diarrhea induced by post-operative antibiotics
An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention o ...
.
BPPV is one of the most common vestibular disorders in people presenting with dizziness; a migraine
Migraine (, ) is a common neurological disorder characterized by recurrent headaches. Typically, the associated headache affects one side of the head, is pulsating in nature, may be moderate to severe in intensity, and could last from a few hou ...
is implicated in idiopathic cases. Proposed mechanisms linking the two are genetic factors and vascular damage to the labyrinth.
Although BPPV can occur at any age, it is most often seen in people older than the age of 60. Besides aging, there are no major risk factors known for BPPV, although previous episodes of head trauma, or the inner ear infection labyrinthitis
Labyrinthitis is inflammation of the labyrinth – a maze of fluid-filled channels in the inner ear. Vestibular neuritis is inflammation of the vestibular nerve – the nerve in the inner ear that sends messages related to motion and position t ...
, may predispose to the future development of BPPV.
Mechanism
The inside of the ear is composed of an organ called the vestibular labyrinth. The vestibular labyrinth includes three semicircular canal
In mathematics (and more specifically geometry), a semicircle is a one-dimensional locus of points that forms half of a circle. The full arc of a semicircle always measures 180° (equivalently, radians, or a half-turn). It has only one line of ...
s, which contain fluids and fine hairlike sensors that act as a monitor to the rotations of the head. Other important structures in the inner ear includes the otolith
An otolith ( grc-gre, ὠτο-, ' ear + , ', a stone), also called statoconium or otoconium or statolith, is a calcium carbonate structure in the saccule or utricle of the inner ear, specifically in the vestibular system of vertebrates. The sa ...
organs, the utricle and saccule, that contain calcium carbonate crystals(otoconia) that are sensitive to gravity.
The crystals may dislodge from the utricle (an otolith organ) and settle within the semicircular canals. When there is motion, the displaced otoconia shift within the endolymph of semicircular canals, causing an unbalanced (with respect to the opposite ear) stimulus, causing symptoms of BPPV.
Diagnosis
The condition is diagnosed by the person's history, and by performing the Dix–Hallpike test
The Dix–Hallpike test — or Nylén–Bárány test — is a diagnostic maneuver from the group of rotation tests used to identify benign paroxysmal positional vertigo (BPPV).
Procedure
When performing the Dix–Hallpike test, patients are lowe ...
or the roll test, or both. The patient can also be asked to induce vertigo by performing a movement that the patient knows to induce vertigo. The eyes of the patient can then easily be observed for which kind ( horizontal, vertical, or diagonal ) of nystagmus is present, to determine which semicircular canal ( horizontal, superior, or posterior ) is affected.
The Dix–Hallpike test is a common test performed by examiners to determine whether the posterior semicircular canal is involved.[ It involves a reorientation of the head to align the posterior semicircular canal (at its entrance to the ]ampulla
An ampulla (; ) was, in Ancient Rome, a small round vessel, usually made of glass and with two handles, used for sacred purposes. The word is used of these in archaeology, and of later flasks, often handle-less and much flatter, for holy water or ...
) with the direction of gravity. This test will reproduce vertigo
Vertigo is a condition where a person has the sensation of movement or of surrounding objects moving when they are not. Often it feels like a spinning or swaying movement. This may be associated with nausea, vomiting, sweating, or difficulties w ...
and nystagmus
Nystagmus is a condition of involuntary (or voluntary, in some cases) eye movement. Infants can be born with it but more commonly acquire it in infancy or later in life. In many cases it may result in reduced or limited vision. Due to the invol ...
characteristic of posterior canal BPPV.[
When performing the Dix–Hallpike test, people are lowered quickly to a ]supine position
The supine position ( or ) means lying horizontally with the face and torso facing up, as opposed to the prone position, which is face down. When used in surgical procedures, it grants access to the peritoneal, thoracic and pericardial regions; ...
, with the neck extended by the person performing the maneuver. For some people, this maneuver may not be indicated, and a modification may be needed that also targets the posterior semicircular canal
The semicircular canals or semicircular ducts are three semicircular, interconnected tubes located in the innermost part of each ear, the inner ear. The three canals are the horizontal, superior and posterior semicircular canals.
Structure
The ...
. Such people include those who are too anxious about eliciting the uncomfortable symptoms of vertigo, and those who may not have the range of motion necessary to comfortably be in a supine position. The modification involves the person moving from a seated position to side-lying ''without'' their head extending off the examination table, such as with Dix–Hallpike. The head is rotated 45 degrees away from the side being tested, and the eyes are examined for nystagmus. A positive test is indicated by the patient report of a reproduction of vertigo and clinician observation of nystagmus. Both the Dix–Hallpike and the side-lying testing position have yielded similar results, and as such the side-lying position can be used if the Dix–Hallpike cannot be performed easily.
The roll test can determine whether the horizontal semicircular canal
The semicircular canals or semicircular ducts are three semicircular, interconnected tubes located in the innermost part of each ear, the inner ear. The three canals are the horizontal, superior and posterior semicircular canals.
Structure
The ...
is involved.[ The roll test requires the person to be in a supine position with their head in 30° of cervical flexion. Then the examiner quickly rotates the head 90° to the left side, and checks for vertigo and nystagmus. This is followed by gently bringing the head back to the starting position. The examiner then quickly rotates the head 90° to the right side and checks again for vertigo and nystagmus.][ In this roll test, the person may experience vertigo and nystagmus on both sides, but rotating toward the affected side will trigger a more intense vertigo. Similarly, when the head is rotated toward the affected side, the nystagmus will beat toward the ground and be more intense.][
As mentioned above, both the Dix–Hallpike and roll test provoke the signs and symptoms in subjects with archetypal BPPV. The signs and symptoms people with BPPV experience are typically a short-lived vertigo and observed nystagmus. In some people, although rarely, vertigo can persist for years. Assessment of BPPV is best done by a medical ]health professional
A health professional, healthcare professional, or healthcare worker (sometimes abbreviated HCW) is a provider of health care treatment and advice based on formal training and experience. The field includes those who work as a nurse, physician (suc ...
skilled in the management of dizziness disorders, commonly a physiotherapist
Physical therapy (PT), also known as physiotherapy, is one of the allied health professions. It is provided by physical therapists who promote, maintain, or restore health through physical examination, diagnosis, management, prognosis, patien ...
, audiologist
Audiology (from Latin , "to hear"; and from Greek , ''-logia'') is a branch of science that studies hearing, balance, and related disorders. Audiologists treat those with hearing loss and proactively prevent related damage. By employing vario ...
, or other physician
A physician (American English), medical practitioner (Commonwealth English), medical doctor, or simply doctor, is a health professional who practices medicine, which is concerned with promoting, maintaining or restoring health through th ...
.
The nystagmus associated with BPPV has several important characteristics that differentiate it from other types of nystagmus.
* Latency of onset: there is a 5–10 second delay prior to onset of nystagmus
* Nystagmus lasts for 5–60 seconds
* Positional: the nystagmus occurs only in certain positions
* Repeated stimulation, including via Dix–Hallpike maneuvers, cause the nystagmus to fatigue or disappear temporarily
* Rotatory/torsional component is present, or (in the case of lateral canal involvement) the nystagmus beats in either a geotropic (toward the ground) or ageotropic (away from the ground) fashion
* Visual fixation suppresses nystagmus due to BPPV
Although rare, CNS disorders can sometimes present as BPPV. A practitioner should be aware that if a person whose symptoms are consistent with BPPV, but does not show improvement or resolution after undergoing different particle repositioning maneuvers — detailed in the Treatment section below — need to have a detailed neurological assessment and imaging performed to help identify the pathological condition.[
]
Differential diagnosis
Vertigo
Vertigo is a condition where a person has the sensation of movement or of surrounding objects moving when they are not. Often it feels like a spinning or swaying movement. This may be associated with nausea, vomiting, sweating, or difficulties w ...
, a distinct process sometimes confused with the broader term, dizziness
Dizziness is an imprecise term that can refer to a sense of disorientation in space, vertigo, or lightheadedness. It can also refer to disequilibrium or a non-specific feeling, such as giddiness or foolishness.
Dizziness is a common medical c ...
, accounts for about six million clinic visits in the United States every year; between 17 and 42% of these people are eventually diagnosed with BPPV.[
Other causes of vertigo include:
* ]Motion sickness
Motion sickness occurs due to a difference between actual and expected motion. Symptoms commonly include nausea, vomiting, cold sweat, headache, dizziness, tiredness, loss of appetite, and increased salivation. Complications may rarely include d ...
/motion intolerance: a disjunction between visual stimulation, vestibular stimulation, and/or proprioception
Proprioception ( ), also referred to as kinaesthesia (or kinesthesia), is the sense of self-movement, force, and body position. It is sometimes described as the "sixth sense".
Proprioception is mediated by proprioceptors, mechanosensory neurons ...
* Visual exposure to nearby moving objects (examples of optokinetic stimuli include passing cars and falling snow)
* Other diseases: (labyrinthitis
Labyrinthitis is inflammation of the labyrinth – a maze of fluid-filled channels in the inner ear. Vestibular neuritis is inflammation of the vestibular nerve – the nerve in the inner ear that sends messages related to motion and position t ...
, Ménière's disease
Ménière's disease (MD) is a disease of the inner ear that is characterized by potentially severe and incapacitating episodes of vertigo, tinnitus, hearing loss, and a feeling of fullness in the ear. Typically, only one ear is affected initial ...
, and migraine
Migraine (, ) is a common neurological disorder characterized by recurrent headaches. Typically, the associated headache affects one side of the head, is pulsating in nature, may be moderate to severe in intensity, and could last from a few hou ...
, etc.)
Treatment
Repositioning maneuvers
A number of maneuvers have been found to be effective including the Epley maneuver
The Epley maneuver or repositioning maneuver is a maneuver used by medical professionals to treat one common cause of vertigo, benign paroxysmal positional vertigo (BPPV) of the posterior or anterior canals of the ear. The maneuver works by all ...
, the Semont maneuver
Benign paroxysmal positional vertigo (BPPV) is a disorder arising from a problem in the inner ear. Symptoms are repeated, brief periods of vertigo with movement, characterized by a spinning sensation upon changes in the position of the head.
* T ...
, and to a lesser degree Brandt–Daroff exercises
Benign paroxysmal positional vertigo (BPPV) is a disorder arising from a problem in the inner ear. Symptoms are repeated, brief periods of vertigo with movement, characterized by a spinning sensation upon changes in the position of the head.
* ...
. Both the Epley and the Semont maneuvers are equally effective. None of these maneuvers addresses the presence of the particles (otoconia); rather it changes their location. The maneuvers aim to move these particles from some locations in the inner ear that cause symptoms such as vertigo and reposition them to where they do not cause these problems. These maneuvers are easily performed at home and online resources are available to patients. The Epley maneuver is the most popular of the maneuvers because it is designed to address particles in the posterior semicircular canal, the most common cause of BPPV. This might give the wrong impression that the Epley maneuver is the cure for all BPPV. Misdiagnosing which semicircular canal is affected, typically by confusing horizontal and diagonal nystagmus, or simply ignoring the identification of the affected canal, results regularly in no cure. Using the appropriate maneuver for the affected canal is essential. The maneuvers are uncomfortable for the patient as they induce strong vertigo and the patient might resist performing them. If the maneuver is not uncomfortable then most likely the wrong maneuver has been selected by a misdiagnosis of the affected semicircular canal. All the maneuvers consist of a series of steps in which the head is held in a specific position, typically for 30 to 60 seconds until nystagmus stops. Movement from one position to the position of the next step has to be done fluently to give the particles enough momentum to move. A position has to be held until nystagmus has completely resided, which indicates that the particles have stopped moving, before one proceeds to the next step.
Epley maneuver
The Epley maneuver employs gravity
In physics, gravity () is a fundamental interaction which causes mutual attraction between all things with mass or energy. Gravity is, by far, the weakest of the four fundamental interactions, approximately 1038 times weaker than the stro ...
to move the calcium
Calcium is a chemical element with the symbol Ca and atomic number 20. As an alkaline earth metal, calcium is a reactive metal that forms a dark oxide-nitride layer when exposed to air. Its physical and chemical properties are most similar to ...
crystal build-up from the posterior semicercular canal ( resulting in diagonal nystagmus ) that causes the condition. This maneuver can be performed during a clinic visit by health professionals, or taught to people to perform at home, or both.[ Postural restriction after the Epley maneuver increases its effect somewhat.]
When practiced at home, the Epley maneuver is more effective than the Semont maneuver. The most effective repositioning treatment for posterior canal BPPV is the therapist-performed Epley combined with home-practiced Epley maneuvers. Devices such as the DizzyFIX
The DizzyFIX is a home medical device designed to assist in the treatment of benign paroxysmal positional vertigo (BPPV) and its associated vertigo. The device is a head-worn representation of semi-circular canals. The device is filled with fluid ...
can help users conduct the Epley maneuver at home, and are available for the treatment of BPPV.
Lempert maneuver or Roll maneuver
For the lateral (horizontal) canal, resulting in horizontal nystagmus, the Lempert maneuver has been used for productive results. It is unusual for the lateral canal to respond to the canalith repositioning procedure used for the posterior canal BPPV. Treatment is therefore geared toward moving the canalith from the lateral canal into the vestibule.
The roll maneuver or its variations are used, and involve rolling the person 360 degrees in a series of steps to reposition the particles.[ This maneuver is generally performed by a trained ]clinician
A clinician is a health care professional typically employed at a skilled nursing facility or clinic. Clinicians work directly with patients rather than in a laboratory or as a researcher. A clinician may diagnose, treat, and otherwise care for pa ...
who begins seated at the head of the examination table with the person supine There are four stages, each a minute apart, and at the third position the horizontal canal is oriented in a vertical position with the person's neck flexed and on forearm and elbows. When all four stages are completed, the head roll test is repeated, and if negative, treatment ceases.
Deep head hanging maneuver
For the superior ( also called anterior ) semicircular canal, resulting in vertical nystagmus, the Deep head hanging maneuver is used. The patient lays down on their back on a bed with their head overhanging the bed.
In the first step the head is turned as backward (hanging) as possible. In the following step, the patient remains lying but lifts their head with the chin close to the chest. In the last step, the patient sits upright with the head in the normal position. Before going to the next step, one has to wait until the nystagmus fully resides ( typical 30 to 60 seconds ) and progression from one step to the next has to happen in a fluid movement.
Semont maneuver
The Semont maneuver has a cure rate of 90.3%. It is performed as follows:
# The person is seated on a treatment table with their legs hanging off the side of the table. The therapist then turns the person's head 45 degrees toward the unaffected side.
# The therapist then quickly tilts the person so they are lying on the affected side. The head position is maintained, so their head is turned up 45 degrees. This position is maintained for 3 minutes. The purpose is to allow the debris to move to the apex of the semicircular duct.
# The person is then quickly moved so they are lying on the unaffected side with their head in the same position (now facing downward 45 degrees). This position is also held for 3 minutes. The purpose of this position is to allow the debris to move toward the exit of the semicircular duct.
# Finally, the person is slowly brought back to an upright seated position. The debris should then fall into the utricle of the canal and the symptoms of vertigo should decrease or end completely.
Some people will only need one treatment, but others may need multiple treatments, depending on the severity of their BPPV. In the Semont maneuver, as with the Epley maneuver, people are able to achieve canalith repositioning by themselves.
Brandt–Daroff exercises
The Brandt–Daroff exercises may be prescribed by the clinician as a home treatment method, usually in conjunction with particle-repositioning maneuvers or in lieu of the particle-repositioning maneuver. The exercise is a form of habituation exercise, designed to allow the person to become accustomed to the position that causes the vertigo
Vertigo is a condition where a person has the sensation of movement or of surrounding objects moving when they are not. Often it feels like a spinning or swaying movement. This may be associated with nausea, vomiting, sweating, or difficulties w ...
symptoms. The Brandt–Daroff exercises are performed in a similar fashion to the Semont maneuver; however, as the person rolls onto the unaffected side, the head is rotated toward the affected side. The exercise is typically performed 3 times a day with 5–10 repetitions each time, until symptoms of vertigo have resolved for at least 2 days.
Medications
Medical treatment with anti-vertigo medications may be considered in acute, severe exacerbation of BPPV, but in most cases are not indicated. These primarily include drugs of the antihistamine
Antihistamines are drugs which treat allergic rhinitis, common cold, influenza, and other allergies. Typically, people take antihistamines as an inexpensive, generic (not patented) drug that can be bought without a prescription and provides re ...
and anticholinergic
Anticholinergics (anticholinergic agents) are substances that block the action of the neurotransmitter called acetylcholine (ACh) at synapses in the central and peripheral nervous system.
These agents inhibit the parasympathetic nervous system ...
class, such as meclizine
Meclizine, sold under the brand name Bonine, among others, is an antihistamine used to treat motion sickness and dizziness (vertigo). It is taken by mouth. Effects generally begin in an hour and last for up to a day.
Common side effects incl ...
[ and ]hyoscine butylbromide
Hyoscine butylbromide, also known as scopolamine butylbromide and sold under the brandname Buscopan among others, is an anticholinergic medication used to treat crampy abdominal pain, esophageal spasms, renal colic, and bladder spasms. It is a ...
(scopolamine), respectively. The medical management of vestibular syndromes has become increasingly popular over the last decade, and numerous novel drug therapies (including existing drugs with new indications) have emerged for the treatment of vertigo/dizziness syndromes. These drugs vary considerably in their mechanisms of action, with many of them being receptor- or ion channel-specific. Among them are betahistine
Betahistine, sold under the brand name Serc among others, is an anti-vertigo medication. It is commonly prescribed for balance disorders or to alleviate vertigo symptoms. It was first registered in Europe in 1970 for the treatment of Ménière ...
or dexamethasone
Dexamethasone is a glucocorticoid medication used to treat rheumatic problems, a number of skin diseases, severe allergies, asthma, chronic obstructive lung disease, croup, brain swelling, eye pain following eye surgery, superior vena cav ...
/gentamicin
Gentamicin is an antibiotic used to treat several types of bacterial infections. This may include bone infections, endocarditis, pelvic inflammatory disease, meningitis, pneumonia, urinary tract infections, and sepsis among others. It is not e ...
for the treatment of Ménière's disease
Ménière's disease (MD) is a disease of the inner ear that is characterized by potentially severe and incapacitating episodes of vertigo, tinnitus, hearing loss, and a feeling of fullness in the ear. Typically, only one ear is affected initial ...
, carbamazepine
Carbamazepine (CBZ), sold under the trade name Tegretol among others, is an anticonvulsant medication used primarily in the treatment of epilepsy and neuropathic pain. It is used as an adjunctive treatment in schizophrenia along with other m ...
/oxcarbazepine
Oxcarbazepine, sold under the brand name Trileptal among others, is a medication used to treat epilepsy. For epilepsy it is used for both focal seizures and generalized seizures. It has been used both alone and as add-on therapy in people with ...
for the treatment of paroxysmal dysarthria
Dysarthria is a speech sound disorder resulting from neurological injury of the motor component of the motor–speech system and is characterized by poor articulation of phonemes. In other words, it is a condition in which problems effectively ...
and ataxia
Ataxia is a neurological sign consisting of lack of voluntary coordination of muscle movements that can include gait abnormality, speech changes, and abnormalities in eye movements. Ataxia is a clinical manifestation indicating dysfunction of ...
in multiple sclerosis
Multiple (cerebral) sclerosis (MS), also known as encephalomyelitis disseminata or disseminated sclerosis, is the most common demyelinating disease, in which the insulating covers of nerve cells in the brain and spinal cord are damaged. This d ...
, metoprolol
Metoprolol, sold under the brand name Lopressor, among others, is a selective β1 receptor blocker medication. It is used to treat high blood pressure, chest pain due to poor blood flow to the heart, and a number of conditions involving an a ...
/topiramate
Topiramate, sold under the brand name Topamax among others, is a carbonic anhydrase inhibitor medication used to treat epilepsy and prevent migraines. It has also been used in alcohol dependence. For epilepsy this includes treatment for gener ...
or valproic acid
Valproate (VPA) and its valproic acid, sodium valproate, and valproate semisodium forms are medications primarily used to treat epilepsy and bipolar disorder and prevent migraine headaches. They are useful for the prevention of seizures in those ...
/tricyclic antidepressant
Tricyclic antidepressants (TCAs) are a class of medications that are used primarily as antidepressants, which is important for the management of depression. They are second-line drugs next to SSRIs. TCAs were discovered in the early 1950s and wer ...
for the treatment of vestibular migraine
Migraine (, ) is a common neurological disorder characterized by recurrent headaches. Typically, the associated headache affects one side of the head, is pulsating in nature, may be moderate to severe in intensity, and could last from a few hou ...
, and 4-aminopyridine for the treatment of episodic ataxia type 2 and both downbeat and upbeat nystagmus
Nystagmus is a condition of involuntary (or voluntary, in some cases) eye movement. Infants can be born with it but more commonly acquire it in infancy or later in life. In many cases it may result in reduced or limited vision. Due to the invol ...
. These drug therapies offer symptomatic treatment, and do not affect the disease process or resolution rate. Medications may be used to suppress symptoms during the positioning maneuvers if the person's symptoms are severe and intolerable. More dose-specific studies are required, however, in order to determine the most effective drug(s) for both acute symptom relief and long-term remission of the condition.
Surgery
Surgical treatments, such as a semi-circular canal occlusion, exist for severe and persistent cases that fail vestibular rehabilitation (including particle repositioning and habituation therapy). As they carry the same risks as any neurosurgical procedure, they are reserved as last resorts.
References
Further reading
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External links
{{Hearing and balance
Diseases of inner ear
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