Benign paroxysmal positional vertigo (BPPV) is the most common vertigo inducing vestibular disorder.
Most commonly BPPV is caused by debris (otoconia) collecting in the posterior semicircular canal in either ear.
A benign condition that is not caused by a serious central nervous system disease
Diagnosis is based on the patient's history and clinical findings.
The patient is informed of the benign nature and good prognosis of the condition and is encouraged to move around freely.
Prevalence and significance
BPPV is most common in middle aged and elderly people. It can, however, also affect younger individuals particularly following a head trauma.
About 25% of all patients who present with vertigo have BPPV.
BPPV can occur concomitantly with other vertigo-inducing diseases and worsen their clinical course. For example, the prevalence of BPPV among patients with Ménière's disease is higher than in the general population.
Undiagnosed and untreated BPPV significantly impairs the patient's functional capacity, mood and quality of life. If left untreated BPPV may cause an elderly patient to be admitted to a care facility as he/she becomes prone to falls, which may lead to a hip or other fracture, and is no longer able to cope at home. Patients of working age may, for example, need to be absent from work.
Pathophysiology
The vestibular system is located in the inner ear and consists of three semicircular canals and two membranous swellings, the saccule and the utricle.
The saccule and the utricle are also known as the otholith organs. When debris that forms within these organs travels to the semicircular canals the person experiences vertigo that is associated with head rotation.
In about 85-95% of cases BPPV is caused by debris collecting in the posterior semicircular canal in the inner ear. In the remainder of cases BPPV is caused by debris in the lateral (horizontal) semicircular canal, and (very rarely) BPPV is caused by symptoms originating from the anterior semicircular canal or from several canals (canalolithiasis). Rarely the debris adheres to the end-organ of the canals, the ampullary cupula, causing positional vertigo (cupulolithiasis).
Diagnosis
BPPV is diagnosed when the patient gives a typical history and the Dix-Hallpike test is positive.
The patient has posterior semicircular canal BPPV when
the patient describes repeated episodes of vertigo associated with turning of the head or changing position
the Dix-Hallpike test provokes typical nystagmus with a latency of 5-20 seconds and with a rotary and vertical component beating towards the affected ear during the fast phase. With repeat testing, the response declines; the vertigo and nystagmus usually resolve within one minute.
Before the test is carried out, the different stages of the test should be explained to the patient. A neck injury or other skeletal problem that would prevent carrying out the test must be excluded.
The test: The patient sits initially on the examination table, and the examiner rotates the patient's head by 45° to the right. The examiner then helps the patient to lie down backwards quickly on the right ear with the head held in slight extension (about 20° below the horizontal level). The examiner observes the patient's eyes for possible nystagmus noting its latency, direction and duration. The patient is also asked about vertigo and how he/she is feeling. The test is repeated on the left side. Frenzel goggles may be used during the test; they prevent the patient from achieving visual fixation and they assist the examiner in observing an even slight nystagmus.
Imaging studies, laboratory investigations, hearing tests and balance studies yield no extra information for the diagnostics. They are only of benefit for the purposes of differential diagnosis if the diagnosis remains unconfirmed.
Differential diagnosis
Vertigo may be caused by a variety of aetiologies.
Ménière's disease is accompanied by ear symptoms, fluctuating hearing loss and the episodes last longer.
In vestibular neuritis and labyrinthitis the symptom duration is longer, i.e. from several days to weeks.
A perilymphatic fistula causes vertigo particularly with pressure changes.
In superior semicircular canal dehiscence, i.e. absence of the part of the temporal bone overlying the superior semicircular canal, loud sounds may cause vertigo.
Post-traumatic vertigo is rarer, and the clinical picture may include headache, tinnitus, altered hearing and dizziness.
Vertigo induced by migraine, multiple sclerosis (MS) or tumours
Cerebellar infarction; symptoms other than vertigo are usually present
Panic disorder, orthostatic hypotension, adverse effects of medication (e.g. antihypertensive drugs, antiepileptics) and shoulder/neck tension
Treatment
Various bedside manoeuvres (repositioning procedures) are available for the treatment of posterior semicircular canal BPPV. The most commonly used ones are the Epley manoeuvre Epley Manouvere for Benign Paroxysmal Positional Vertigo and the Semont manoeuvre.
Repositioning procedure therapy has proven to be more effective than exercise training and pharmacotherapy. If the treatment response remains poor, repeating the repositioning procedures is effective.
A large share of patients, however, get well already after the first repositioning procedure.
BPPV may recur even after an asymptomatic period of months.
The Lempert manoeuvre is used in the treatment of lateral semicircular canal BPPV.
A motivated patient may be instructed to carry out the positional exercises at home (give printed patient handout, e.g.http://www.activator.com/wp-content/uploads/Home%20Epley%20Handouts.pdf). For the success of the treatment, a physiotherapist well versed in these manoeuvres plays an important role.
Vestibulosuppressant medication and anxiolytics do more harm than good.
In severe treatment-resistant cases, an ear specialist should be consulted.
References
Liu Y, Wang W, Zhang AB et al. Epley and Semont maneuvers for posterior canal benign paroxysmal positional vertigo: A network meta-analysis. Laryngoscope 2016;126(4):951-5. [PubMed]
Reinink H, Wegner I, Stegeman I et al. Rapid systematic review of repeated application of the epley maneuver for treating posterior BPPV. Otolaryngol Head Neck Surg 2014;151(3):399-406. [PubMed]
Amor-Dorado JC, Barreira-Fernández MP, Aran-Gonzalez I et al. Particle repositioning maneuver versus Brandt-Daroff exercise for treatment of unilateral idiopathic BPPV of the posterior semicircular canal: a randomized prospective clinical trial with short- and long-term outcome. Otol Neurotol 2012;33(8):1401-7. [PubMed]
von Brevern M, Bertholon P, Brandt T ym. Benign paroxysmal positional vertigo: Diagnostic criteria Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society. Acta Otorrinolaringol Esp 2017;68(6):349-360. [PubMed]