Positional Vertigo

 Overview

Benign Paroxysmal Positional Vertigo, BPPV (sometimes also referred to as BPV) is the most common cause of bouts of vertigo in the general population. The hallmark of BPPV is vertigo, i.e. an abnormal sensation of motion (usually spinning), that lasts for a few seconds or up to a minute.

The symptoms are brought on by typical head movements, usually neck extension - such as with looking up at a high shelf or at the sky - or rotation to one side. The vertigo will commonly be felt when going to lie down in bed, or when rolling over to one side while in bed, and for this reason it is frequently first noticed at night or upon awakening.

The vertigo associated with BPPV has 3 other characteristic features:

  • Latency - it begins a few seconds after the provocative head movement.

  • Transience - it spontaneously abates if the provocative position is maintained statically for a period of time (usually 30-60 seconds). For this reason, it should more accurately be called “positioning” vertigo, not “positional” vertigo, since it is movement into the position, not maintenance of the position, that provokes the symptoms.

  • Fatigability - repeated performance of the same movement within a short time results in a decrease in the symptoms. In practice, this last feature is frequently unidentified, because people reflexively try to avoid repeating the movement that provoked the vertigo, rather than trying to extinguish the symptoms with repetition.

In some people, BPPV can be so severe that any movement at all will provoke the vertigo, while in others only very specific, identifiable movements will result in vertigo. If the former is the case, the vertigo may be perceived as continuous since it renders one nearly immobile. However, close attention to the symptoms will usually reveal their motion-provoked nature.

BPPV is thought to be caused by displacement of otoliths (mineral crystals) from the vestibule of the inner ear into the semicircular canals. The posterior semicircular canal is most commonly involved, though the superior and horizontal canals can also be affected. The affected ear and canal can be determined by visual inspection of the eye movements that result from specific positioning of the head in the clinician's office.

With this information, the clinician can then choose an appropriate “particle-repositioning maneuver” to facilitate migration of the crystals out of the semicircular canal into a harmless location back in the vestibule. These maneuvers are painless, and take just a few minutes to perform. In the most common form of BPPV, they are successful in curing the disease with one treatment in about 80% of people. Some people require a second session, and some will require even more to relieve the vertigo. For the procedure to be successful, it is important that the clinician be able to reliably identify the side and site of the problem.

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Brandt-Daroff Exercises

If BPPV is suspected but cannot be confirmed or reliably localized on physical exam, home exercises can help to alleviate the symptoms in many cases. These exercises can also be helpful for people who have repeatedly tried the particle-repositioning maneuver without success, or for people with some residual symptoms after successful particle repositioning.

The most commonly used exercises are those described by Brandt & Daroff.

Sit on the edge of your bed near the middle with legs hanging over the side.

  • Quickly lie down onto your right side and turn your head 45 degrees to the left (toward the ceiling). Hold this position for 30 seconds or until any dizziness passes.

  • Return to the upright position looking straight ahead for 30 seconds.

  • Perform same maneuver to the left side, with head rotated toward the right. Hold the position for 30 seconds or until any dizziness passes.

  • Return to the upright position looking straight ahead for 30 seconds.
Diagram of Brandt and Daroff exercises

The four positions in numbers 1-4 comprise one “set” of the exercises. Complete 5 repetitions of this set in one sitting, for a total of 10 minutes of exercises. Do this 2-3 times a day for 2-3 weeks. If you have no further symptoms after 1 week of exercises, you may decrease to 3-4 times per week with only 2 repetitions of the set per sitting. These exercises should be undertaken only after evaluation by a physician to determine that your problem is in fact caused by BPPV.

Many other disorders can mimic BPPV, and these might require more detailed investigation or other therapies. All vestibular exercises are best performed in a comfortable and safe setting, preferably with an able partner to assist and watch you, to protect against the possibility of falling or otherwise injuring yourself. If you have neck stiffness or other neck problems such as hardening of the arteries, consult a physician before performing these exercises.

For a nice animated depiction of these exercises online go to this site:
http://www.dizziness-and-balance.com/disorders/bppv/bppv.html

If Brandt-Daroff exercises fail to relieve the vertigo, a trial of customized vestibular rehabilitation is indicated.

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Surgery for BPPV

In a few people, probably less than 5%, BPPV cannot be adequately controlled with particle-repositioning maneuvers, Brandt-Daroff exercises or even customized vestibular rehabilitation therapy. In such instances surgery may be indicated. Surgery cannot be undertaken for BPPV unless the correct ear and affected canal have been reliably identified. Surgery has only been described for the posterior semicircular canal, the most commonly affected. In theory, other canals could potentially be addressed, but the risks of hearing loss might be greater in certain circumstances.

The simplest and most reliable surgery is mechanical occlusion of the affected posterior semicircular canal. The canal is exposed via a mastoidectomy, drilling the bone behind the ear, and it is gently opened up and occluded with bone dust and/or other materials. In properly selected patients this procedure will be successful the vast majority of times. Recovery is typically rapid. Some motion-related imbalance may be experienced for a few weeks as the brain recovers from the loss of function from the one canal, but this is usually minor. There can also be a mild degree of hearing loss after the surgery, though this is usually temporary.

Another surgery that has been used for BPPV is division of the singular nerve, the small branch of the inferior vestibular nerve that breaks off to supply the posterior semicircular canal. This surgery is technically more challenging, and less reliable in most Otologist's hands, and has therefore been largely replaced by canal occlusion.

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If you would like to make an appointment or talk to an Audiologist, please call the Hearing and Balance Center at 410-328-5947.

This page was last updated: April 19, 2013

         
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