Tag Archives: Benign paroxysmal positional vertigo

Spinning world: Benign Paroxysmal Positional Vertigo

Dizziness, a common cause of referral to otolaryngology clinic, includes a broad range of sensations from severe vertigo to momentary light-headedness , and Vertigo most common of dizziness  is an illusion of movement of the body or environment.

Vertigo may be because of otologic, neurologic, or systemic reasons.

Causes of Otologic dizziness

  • Benign paroxysmal positional vertigo) – about 50% of otologic, 20% all
  • Meniere’s disease – about 20%
  • Vestibular neuritis and related conditions (15%)
  • Bilateral vestibular loss (about 1%)
  • SCD and Fistula (rare)

What is Benign Paroxysmal Positional Vertigo?

Benign paroxysmal positional vertigo (BPPV) is the most common underlying cause of vertigo accounting for about 20% of all dizziness and 50% of otologic dizziness.

Benign paroxysmal positional vertigo is defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo.

Positional vertigo means a spinning sensation produced by changes in head position relative to gravity.
Benign means not due to any serious brain or CNS (Central Nervous System)disorder  and the overall prognosis for recovery is favorable. (However, undiagnosed and untreated BPPV may have health, and quality-of-life impacts).
Paroxysmal—  means Rapid and sudden onset of the vertigo

Symptoms of BPPV-

Dizziness, Imbalance, Nausea, light-headedness

That is

  • Brief and strong
  • Provoked by change of head position
  • Definitively diagnosed by Hallpike test
  • Many patients wake up with the condition, noticing the vertigo while trying to sit up suddenly.
  • People do not usually feel dizzy all the time. Dizziness attacks triggered by head movements (classically with lying down or rolling over in bed) and between episodes patients usually have few or no symptoms.
  • Classic BPPV is usually triggered by the sudden action of moving from the erect position to the supine position while angling the head 45° toward the side of the affected ear.

The pathophysiology of BPPV –

Normal Ear Anatomy

The labyrinth of the inner ear is composed of the vestibule (utricle and saccule) and the 3 semicircular canals. These are filled with fluid called endolymph and have receptors to inform the brain about the head’s position in space.

Inner Ear

Utricle contains small calcium oxalate crystals called otoliths or otoconia for gravity and position receptors for linear acceleration.

Similarly, angular acceleration receptors are located in the cupula of the semicircular canals. When head turns, these receptors inform the brain via vestibular nerve that the head is turning. Once the head stops turning, the endolymph stops moving, the receptors stop firing, and the brain now knows that the head has stopped turning.

Inner ear semicircular canals-BPPV

In BPPV, the otoliths become dislodged from normal position and accumulate in wrong place in one of the semicircular canals (most commonly in the posterior semicircular canal since it is at the most dependent position)

When the patient turns his head, otoliths move, and trigger faulty signals even after head stops moving. The eyes, however, inform the brain that the head has stopped moving. Brain Receives conflicting information causing brief but intense sense of spinning.

Diagnosis of BPPV—

Comprehensive History is most important aspect. Patient describes his complaints in his own words and a specific set of leading questions specially onset of symptoms, duration, associated eye,  ear and neurologic systems, history of any ear/head trauma, medical disease or medication  are asked by health care provider. While talking to patient usually a diagnosis is established.

Basic ENT and Ear examination is done for concomitant ear problem.

Neurological examination to rule out any CNS lesion is carried out.

Neurotologic examination Evaluation of static disturbances (with head still) and dynamic disturbances (with head motion)

Dix-Hallpike maneuver– Standard clinical test for BPPV

This test is performed by rapidly moving the patient from a sitting position to the supine position with the head turned 45° to the right. After waiting approximately 20-30 seconds, the patient is returned to the sitting position. If no nystagmus is observed, the procedure is then repeated on the left side.

The finding of classic rotatory nystagmus with latency and limited duration is considered pathognomonic. A negative test result is meaningless.

Classic BPPV is the most common variety of BPPV. It involves the posterior Semi Circular Canals.

Diagnostic criteria for posterior canal BPPV
  • History – Patient reports repeated episodes of vertigo with changes in head position.
  • Physical examination each of the following criteria are fulfilled:–
  • Vertigo associated with nystagmus is provoked by the Dix-Hallpike test. There is a latency period between the completion of the Dix-Hallpike test and the onset of vertigo and Nystagmus, Geotropic (means towards earth-refer to upper half of the eyes nystagmus with the problem ear down
  • The provoked vertigo and nystagmus increase and then resolve within a time period of 60 seconds from onset of nystagmus.
  • Reversal upon return to upright position
  • Response decline upon repetitive provocation
Nystagmus is involuntary eye movements (usually triggered by inner ear stimulation) named by the direction of the fast phase. Thus, nystagmus may be horizontal (right beating, left beating, up-beating), vertical (down-beating), or rotational (geotropic-towards earth and ageotropic).

Workup for BPPV

Laboratory Studies

  • Laboratory tests are not needed to make the diagnosis of benign paroxysmal positional vertigo (BPPV).
  • Tests may be advised for other associated inner ear pathology.
  • Blood sugar and routine complete blood count may be done to rule out hypoglycemia and anemia.
  • Electrolyte level may be done if patient had severe episodes of vomiting

Imaging Studies

Imaging studies (CT scan and MRI) are not routinely required for patient with BPPV. In cases of doubt it may be advised.

Other tests

  • Audiogram – simple test which may be done for concomitant ear pathology
  • Caloric test
  • Electronystagmography (ENG)
  • Posturography

Differential diagnoses for benign paroxysmal positional vertigo (BPPV)

  • Ménière disease
  • Inner ear concussion
  • Alcohol intoxication
  • Vestibular labyrinthitis
  • Vascular loop syndrome
  • Lesion of the nodulus from stroke, multiple sclerosis, Arnold-Chiari malformation, ischemia, cerebellar degeneration, and intoxication.
  • Posterior fossa lesion such as acoustic neuroma or meningioma.
  • Vertebral artery insufficiency
  • Cervical vertigo, or head extension vertigo,
  • Orthostatic hypotension,
  • Medication side effects
  • Anxiety or panic disorder
  • Migraine related vertigo
  • Management of BPPV

    Epley Maneuver— Initial and most important management strategy is Canalith repositioning maneuver or CRP or Epley maneuver. ( for details read previous post Canalith repositioning maneuver for BPPV)

    Vestibular Rehabilitation Exercises Vestibular rehabilitation is an exercise program to help compensate for a loss or imbalance within the vestibular system either self-administered or with a clinician.

    Cawthrone cooksey exercises and Brand  Daroff exercises for BPPV are beneficial for hastening of restoration of normal balance.

    Observation – wait and watch with reassurance and follow-up visits as symptoms resolve in 1-2 month time.

    Medical TherapyVestibular suppressant medications can be used but many times not effective and masks the problem.. Adverse effects of grogginess and sleepiness ca occur.

    Health Education – Patients are counseled regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up.

    Surgical Care

    Surgery is reserved for those in whom CRP fails. There is possibility of complications such as hearing loss and facial nerve damage.

    The most viable surgical option is posterior canal occlusion. The aim is to stop the benign positional vertigo by collapsing the posterior canal, immobilizing the movement of particles through the canal.

    Benign Paroxysmal positional vertigo usually is not due to any serious neurological disorder and the overall prognosis for recovery is favorable; however, undiagnosed and untreated BPPV may have safety concerns and quality-of-life impacts.

    Proper Diagnosis and treatment of patients with BPPV may lead to significant health care quality improvements thus it is very important to implement a well-constructed clinical practice guidelines.

    Canalith Repositioning Procedure for Vertigo: Active treatment of BPPV

    Update — in my other posts read more about Benign Paroxysmal Positional Vertigo

    and Home care of vertigo

    Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness, most often experienced when patients lies down.

    Because BPPV is not intrinsically life threatening and symptoms are usually self limiting patient is usually kept under watchful wait but as BPPV can last for much longer than 2 months, it is better to treat it actively by Epley maneuvers or Semont Maneuver. The Semont and Epley maneuvers may improve or cure benign paroxysmal positional vertigo (BPPV) with only one procedure however some people may need multiple sittings.

    CRP / Epley maneuver/  Canalith repositioning procedure

    The Canalith Repositioning Procedure (CRP) or epley’s maneuver is a rehabilitation treatment for Benign positional vertigo.  CRP is very effective, with an approximate cure rate of 80%. The recurrence rate for BPPV after these maneuvers is low. However, in some instances additional treatment may be necessary.

    Canalith/otolith/or otoconia are small crystals of calcium carbonate attached to the otolithic membrane in the utricle of the inner ear. Because of trauma, infection, or aging, canaliths can detach from the utricle and collect within the semicircular canals. Here these canaliths shift with the head movement  and stimulate sensitive nerve endings to cause dizziness.

    Epley’s maneuvers involve a series of specifically patterned head and trunk movements performed by a trained professional. This head position change, moves the canaliths from the problematic location in one of the semicircular canal to the utricle.

    Procedure: The procedure takes approximately 20-30 minutes.

    You will be placed on a table and then laid back with your head hanging over the end of the table.
    If you have a “positive” response in this position you will then be moved through the procedure.

    A. Patient is placed in sitting position on the edge of the examination table (Position A).

    B. Head is rotated 45° towards the affected ear, and the patient is swiftly placed in lying position with the head hanging 30° below the horizontal over the table edge (Position B). Positive response (primary stage nystagmus) is observed position is maintained for 1-2 minutes.

    C. The head is rotated 90° towards the opposite ear while maintaining the head hanging position. (Position C)

    D. Patient is turned further 90° towards the unaffected side to face the floor. (Position D)

    The patient’s eyes are observed for secondary-stage nystagmus, it should be in the same direction as the primary-stage nystagmus.

    E. Position is maintained for 30 to 60 seconds, and then again laced in sitting position (Position E). Upon sitting, there should be no vertigo or nystagmus in a successful maneuver.

    Instructions Following the Canalith Repositioning Procedure

    Wait for 10 minutes after the maneuver is performed before going home. Don’t drive yourself home.

    For first 48 hours

    1. Do not tip your head up or down or bend at the waist. Use of the cervical collar will help prevent you from tipping your chin down.
    2. Do not visit the places that require you to lie down or tilt your head (hairdresser, dentist, chiropractor or barber).
    3. Avoid tipping your head up or down when brushing teeth, shaving or washing your hair.
    4. Sit down and get up from chairs while keeping your back straight, without bending forward and avoid tilting your head forward.
    5. Housework such as cooking or cleaning should be avoided for the next 48 hours.
    • Do Not Lie Flat in Bed:

    Sleep semi-recumbent for the next night. This means sleep with your head halfway between being flat and upright (a 45 degree angle) by using a recliner chair or by using pillows arranged on a couch

    The Following Week:

    • Do Not Sleep on your treated side
    • Use two pillows when you sleep.
    • Avoid sleeping on the “bad” side.
    • Don’t turn your head far up or far down

    (Like head extended positions at the beauty parlor, dentist’s office, and while undergoing minor surgery).

    • No “sit-ups” for at least one week and no “crawl” swimming.

    After 1 week you can resume your daily activities without any restrictions. Move around as you wish.


    Contraindications to perform Epley Maneuver

    • Unstable heart disease
    • High grade carotid stenosis,
    • CNS disease (stroke or Transient Ischemic Attack),
    • Physical limitation– neck disease (rheumatoid arthritis, cervical radiculopathies, ankylosing spondylitis, cervical spine fracture or surgery)
    • Pregnant women beyond the 24th week of pregnancy

    Semont Maneuver

    The Semont maneuver (liberatory” maneuver) involves a procedure whereby the patient is quickly moved from lying on one side to lying on the other side.

    © Liberatory manoeuvre of Semont (right ear)Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003:169:681-693.

    Position 1. Patient is made to sit on the examination table with legs hanging over the edge and head turned 45 degrees horizontally towards the unaffected ear.

    Position 2. While maintaining head rotation patient’s upper body is swiftly moved to side lying position on the affected side with head resting on examination table and nose pointed upwards. Position is maintained for 3 minutes or till vertigo and nystagmus subsides. This step moves the debris to the apex.

    Position 3. Patient is rapidly moved through the sitting position (Position 1) to lying on the opposite or unaffected side (maintaining same head rotation) with nose pointed to the ground. Position is again maintained for 3 minutes or till the vertigo and nystagmus subsides. This maneuver moves the debris towards exit of the canal.

    Idea is to move the debris into the utricle where it will no longer cause vertigo.

    Semont maneuver is 90% effective after 4 treatment sessions

    Update — Next post–Read more about BPPV (Spinning world–Benign Paroxysmal Positional Vertigo)

    and Home care of Vertigo