Presented by:

Charles S. Yanofsky, M.D.

Susquehanna Physician Services

699 Rural Avenue, Ste 205

Williamsport, PA 17701

(570) 321-2820

 

Dizziness Explained: Benign Paroxysmal Positional Vertigo

In my booklet on dizziness I neglected to add a section devoted to this, one of the commonest and easiest to treat causes of vertigo. In our practice 20-30% of patients who present with vertigo have this condition. That is not an accurate count since doctors tend to refer us patients they think have this often eminently treatable condition. Until just a few years ago, not a lot of doctors knew or recognized this condition. Recall that vertigo is an hallucination of movement. Benign Paroxysmal Positional Vertigo (BPPV) is aptly named.

Benign: Once recognized as you will see, though the symptoms are most troublesome, they don’t portend anything serious, threatening life or limb. That is not to say that symptoms aren’t disturbing for those that have them, especially not knowing where they come from, but as you will see, there is no cause for alarm.

Paroxysmal: Vertigo occurs in attacks lasting usually last less than one minute.

Positional: Vertigo happens when you put your head in certain positions, typically in looking up, or classically when you lay down turning on your right or left side, and again, it only lasts for seconds most of the time, but you get a terrible sense of moving or whirling that is fearful and disorienting i.e an hallucination of movement, vertigo, as above described.

Persons with BPPV don’t usually tell us about all of these symptoms and may not notice a lot of pertinent features. The history has to be elicited and an appropriate exam done.

Typically a person will get very dizzy, but may not realize they have vertigo specifically and sometimes they have a sensation a little short of vertigo, sort of a disorienting dizziness that is usually transitory. They may experience it as they look up as in painting a ceiling or while at the beauty parlor or when they get in certain positions working on their car or gardening etc. Sometimes symptoms are at their worst in the morning and often they are not aware until our exam brings this out, that vertigo occurs when they lay on one side. Some persons know this and some do not, but this is often a telltale symptom. Though vertigo is transitory it is so uncomfortable that some are not aware it only lasts seconds and when it has been present for a long time, some hapless victims start avoiding all kinds of activities for fear something awful will occur. I’ve seen lots of people who won’t drive and some who won’t even leave their house , They are so fearful they will get into an accident or something dangerous will occur, but it rarely does. This vertiginous sensation can rarely develop into what is called agorophobia, fear of going out and literally changes some person’s lives.

As it turns out someone with this condition does not only have vertigo but may have an array of other symptoms which goes along with vertigo, very often a sense of imbalance on one’s feet, unsteadiness, nausea, general dysequalibrium, anxiety, even tilting, and jumpiness of vision. Older folks rarely may be caused to fall as this contributes to general gait unsteadiness.

Diagnosing BPPV:

When a person has typical symptoms, making a diagnosis isn’t difficult. We always get a complete medical history and conduct a thorough physical exam, but we can be fairly confident in the diagnosis (other conditions being excluded) in doing a so-called Hallpike maneuver (variously called a Dix-Hallpike or Nylen-Barany maneuver). Here you are asked to sit on an examining table, your head tilted back and to the right (then the left when the test is repeated) about 45 degrees. We lay you down in this position so that the right and on repetition then the left ear is hanging down. After an appropriate interval, if we catch you during a symptomatic period, you will have nystagmus visible to the observer and at roughly the same time, you will experience vertigo. As I talk about in  Dizziness Explained vertigo is married to nystagmus. Nystagmus is a jerking movement of your eyes visible to your examiner. The physician will describe these eye jerks in detail and can ordinarily localize the problem precisely to one of the ear canals, most frequently the posterior canal on the right or left side. Sometimes the exam is problematical. Some persons are very afraid of being tilted and manipulated because this is the very thing that brings on their troublesome symptoms and they studiously avoid such movements. Sometimes the sufferer just happens to come in when they are not symptomatic or they have a problem that is difficult to localize. Some persons have the problem in both ears. Then we may not see so clearly and other test, typically an ENG (pls see Dizziness Explained for an explanation) may be necessary. I’d say the majority of persons who come into our office have seen a number of other doctors, have had a variety of tests, often an MRI.

Causes of BPPV:

The ear contains tiny sand grains of Calcium Carbonate call otoliths which literally means ear rocks. These fellows are meant to be heavy and like to fall on receptors in the ear called hair cells when you tilt your head. In this way your inner ear relays information to your brain about the position of your head. Lots of times these little rocks come off of their membrane and break free going from a part of the inner ear called the utricle falling into one of the semicircular canals, most commonly the posterior canal. I’ve borrowed a figure from Tim Hain, MD an expert on dizziness, but such pictures are readily available from a lot of sources.

 

This is technical but sometimes the displaced otoconia are not actually in the canal but are stuck in the wrong position so that you will have actually a more prolonged vertigo sensation and the examiner will see more prolonged nystagmus as well.

What caused the otoconia to break loose? In younger persons it may be trauma or a head injury and I’ve often seen BPPV follow vestibular neuritis another condition described in our booklet and elsewhere. In older folks the condition is even more common, possibly the effect of cumulative movement and trauma throughout life or "degeneration" related to age.

Treatment:

Treatment is aimed at trying to get those pesky otoconia back into position and it is something like the Hallpike maneuver that is done to diagnose the condition. This is called Canalith repositioning. The otoliths now being in the canal where they don’t belong are called canaliths, canal rocks. The most typical treatment though not the only one available is the Epley maneuver done in the office. We basically utilize gravity to get those little guys back into the right position and it almost always is effective. After a treatment often the patient is a little wifty or dizzy, somewhat off and we don’t like to let them drive home for that reason and because the situation has to be allowed to settle and we encourage a person not to move or turn their neck then to sleep for a week or so, at about 30 degrees and avoid turning. Sometimes an Epley may be repeated or often we also prescribe what are called Brandt-Daroff exercises that aim to do the same thing as a home treatment. Exercises are a little less efficacious in that they have to be repeated many times before a person typically sees any effect.

What Happens Without Treatment?

Nothing terrible usually. That’s why the problem is felt to be benign. A lot of times it comes and goes. It may recede for a while, sometimes years, then inexpliquably recur. It may get better and never occur again. A lot of people we see have had the problem for a long time and some persons learn to avoid certain positions or even activities and find that the problem limits their lives. Of course, it’s important to be sure you really have this and not something else that may masquerade as this condition, but that is rarely the case. We enjoy treating people with BPPV because it is rare in neurology that we can provide treatment with such a dramatic positive result. Occasionally the otoliths will come loose again and somewhere down the road, you may require further treatments.

Revised 10/19/99. © 1999 Charles Yanofsky

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