Benign Paroxysmal Positional Vertigo



Benign paroxysmal positional vertigo is a disorder caused by problems in the inner ear. Its symptoms are repeated episodes of positional vertigo, that is, of a spinning sensation caused by changes in head position.

Dizziness accounts for about 6 million clinic visits in the U.S. every year, and 17–42% of these patients eventually are diagnosed with BPPV.

Within the labyrinth of the inner ear lie collections of calcium crystals known as otoconia. In patients with BPPV, the otoconia are dislodged from their usual position within the utricle and they migrate over time into one of the semicircular canals (the posterior canal is most commonly affected due to its anatomical position). When the head is reoriented relative to gravity, the gravity-dependent movement of the heavier otoconial debris within the affected semicircular canal causes abnormal (pathological) fluid endolymph displacement and a resultant sensation of vertigo. This more common condition is known as canalithiasis. In rare cases, the crystals themselves can adhere to a semicircular canal cupula rendering it heavier than the surrounding endolymph. Upon reorientation of the head relative to gravity, the cupula is weighted down by the dense particles thereby inducing an immediate and maintained excitation of semicircular canal afferent nerves. This condition is termed cupulolithiasis.

It can be triggered by any action which stimulates the posterior semi-circular canal which may include tilting the head, rolling over in bed, ooking up or under or sudden head motions.

The condition is diagnosed from patient history (feeling of vertigo with sudden changes in positions); and by performing the Dix-Hallpike maneuver or Horizontal Roll Test which are diagnostic for the condition. The test involves a reorientation of the head to align the canal with the direction of gravity. This test stimulus is effective in provoking the symptoms in subjects suffering from archetypal BPPV. These symptoms are typically a short lived vertigo, and observed nystagmus. If symptoms do not resolves within 8-10 seconds, this is a positive test for cupulolithiasis (symptoms typically are delated and last more than a minute).

The most effective treatments for relieving symptoms of BPPV include the Epley Maneuver (for anterior and posterior canalithiasis/cupulolithiasis), or the Appiani Maneuver (less common include the BBQ Roll and the Brandt-Daroff) (for horizontal canalithiasis/cupulolithiasis). The Epley and Appiani employ gravity to move the calcium build-up that causes the condition. This particle repositioning maneuver can be performed during a clinic visit by specially trained physical therapists. The maneuver is relatively simple but few general health practitioners know how to perform it. The Epley maneuver does not address the actual presence of the particles (otoconia), rather it changes their location. The maneuver moves these particles from areas in the inner ear which cause symptoms, such as vertigo, and repositions them into areas where they do not cause these problems.

Dix Hallpike (tests for anterior and posterior canalithiasis)
Horizontal Roll Test (tests for horizontal canalithiasis)
Epley Manuver (anterior and posterior canal BPPV)
Appiani Maneuver (horizontal canal BPPV)
BPPV PT Treatment Flowsheet
Vestibular Anatomy.

Meclizine is a commonly prescribed medication, but is ultimately ineffective for this condition, other than masking the dizziness. Other sedative medications help mask the symptoms associated with BPPV but do not affect the disease process or resolution rate. Betahistine (trade name Serc) is available in some countries and is commonly prescribed but again it is likely ineffective. Particle repositioning remains the current gold standard treatment for most cases of BPPV.

Surgical treatments, such as a semi-circular canal occlusion, do exist for BPPV but carry the same risk as any neurosurgical procedure. Surgery is reserved for severe and persistent cases which fail particle repositioning and medical therapy.

Supporting Research

Clinical practice guideline: Benign paroxysmal positional vertigo

Benign Paroxysmal Positional Vertigo – contains excellent diagrams of maneuvers

Dizziness and Balance – website with lots of excellent information.