Benign Paroxysmal Positional Vertigo (BPPV)

First let’s talk about nomenclature. Vertigo technically refers to a symptom, not a disease. Strictly, vertigo means the sensation of the room spinning around you. This could have many different reasons. Sometimes, if we are not able to readily diagnose the source of the symptoms of vertigo, we might use vertigo as a diagnosis, but that is not terribly accurate. 

Benign paroxysmal positional vertigo (BPPV) refers to one specific type of dizziness that comes with vertigo. As the name implies, this is not due to some terribly dangerous condition. Paroxysmal means that it happens in specific bouts, but it is not constant. Positional means that a certain position makes it happen again and again, but other positions do not elicit the same reaction.  

Within our inner ears, we have the organ of hearing and organ of balance. Although technically separate, they are considered to be two ends of the same organ. In the organ of balance, we have a sack of liquid as well as 3 circular canals that also contain liquid.  As we move our heads, the liquid drags behind and the motion of the liquid within those compartments is what helps us keep our balance.

Occasionally, small crystals form within the liquid chambers. If we then move our head in a specific direction where the crystals within one of those canals is stuck, we get sudden sensation of vertigo. Typically this is repeatable every single time the head is moved in that one direction. Most patients feel sudden onset of vertigo that lasts less than one minute. There might be some lightheadedness that follows, but typically the vertigo goes away. The first time that many patients experience BPPV, the symptoms may be very severe, resulting in nausea and vomiting as well.  Many people describe that subsequent events are strictly limited to few seconds, and the vertigo then goes away without major consequences.  

Some of the more common situations that elicit the repeated bouts of positional vertigo are laying down in bed and rolling to the affected side, yoga positions were the head is down typically lower than the rest of the body, tilting the head back and looking up at the ceiling, etc.  Positional vertigo rarely results in loss of consciousness, falls, or headaches.

For many patients the crystal goes away by itself after a few days or even a few weeks, and the symptoms disappear. Some people are prone to forming the crystals again in the future. Most of the time the crystal forms on the same side, but occasionally it could be on the opposite side. Most people who experience positional vertigo have the crystal on one side, but 15% of the people might have crystals on both sides at the same time.  There are no medications to prevent the formation of future crystals, but common sense says that hydration might lessen the concentration of the minerals that eventually could stick together and form a new crystal.

If the crystal is still stuck and is not going away, the best remedy is to perform the Eply maneuver.  You can find the instructions here. It is rather important to first determine which side the crystal is on, and then perform the Eply maneuver on the affected side. Many people get dramatically better after the very first time the maneuver is performed. However, I do recommend for patients to perform this at home a few more times for maximum benefit. Many people with repeated bouts of positional vertigo also become adept at performing the maneuver on their own as soon as new symptoms arise.

There is no specific medications that could be used to treat BPPV. Some people might benefit from Meclizine or Dramamine to lessen the severity of the symptoms. Some may also benefit from anxiety medications to help them cope with the situation. For some people, Vestibular Therapy might be helpful in getting any leftover symptoms resolved as well. If the patient does not respond to the above remedies then we have to question if positional vertigo is the right diagnosis, and perform additional work up to rule out other reasons for the vertigo.

I recommend all patients who are suspicious of suffering from positional vertigo to see their Ear Nose and Throat specialist to confirm the diagnosis, and to perform the Eply maneuver with them at least the very first time. It is important to keep an open mind that not all dizziness is vertigo, and not all vertigo is BPPV.

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Posted in: Ears

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