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Lynn S. Alvord PhD
BPPV (Benign paroxysmal positional vertigo)
BPPV, refers to “benign paroxysmal positional vertigo”, or simply, “benign positional vertigo” (BPV). (The term “paroxysmal” means occurring suddenly and intensely, such as “the crowd burst into paroxysms of laughter”.)
BPPV is one of the most common causes of dizziness (vertigo), accounting for 18% of patients seen in dizzy clinics and a general prevalence of about 2.4% in the population (Nedzelski JM, Barber HO, McIlmoyl L. Diagnoses in a dizziness unit. J Otolaryngol 1986; 15:101). Prevalence is far greater than these figures in older patients and somewhat more prevalent in women than men. These numbers probably greatly underestimate the incidence of BPPV. Because these figures are somewhat dated, and with the much greater recognition lately of BPPV by the medical community in general, the incidence is likely to be much higher. It is my observation that many clinicians are not recognizing BPPV or are testing for it in the wrong way. See below for more about this.
BPPV is caused when inner ear “crystals” are in the wrong spot within the inner ear balance system. See figure below.
(Insert Figure – Utricle and semicircular canals with crystals in posterior canal)
These calcium carbonate crystals are normally found in the inner ear by the thousands, but should be found only in the utricle and saccule where they sit atop hair cells sensitive to motion. In these locations, the crystals actually help the balance system by lending weight to the hair cells helping them bend. The saccule senses head movement in the “up or down” directions, while the utricle senses head movement in forward-backward or other linear directions such as side to side.
(Insert Picture of crystals on top of hair cells)
When particles become dislodged due to natural attrition, age, a blow to the head, or disturbance by a virus, etc., they can fall into one of the semi-circular canals. Then, when the head moves into certain triggering positions such as rolling in bed or looking up, a brief episode of vertigo can occur due to disturbance by the crystals of nerve areas in one of the maculae (bulging areas at the end of each semi-circular canal). This “positional” vertigo can occur every time such a head position is assumed or may be somewhat unpredictable. Other common provoking head positions include bending down or looking back over the shoulder. In addition to the vertigo, overall balance can be negatively affected as well.
BPPV can occur at any age, but ironically the sensation of vertigo is often much reduced or even absent in older persons even though the negative effect on balance can remain, often leading to serious falls. For this reason, older fall-prone patients should be routinely tested for BPPV even if they deny symptoms of vertigo. See Dix-Hallpike test below.
The symptoms of BPPV in young to middle aged patients consist of a severe, sudden, brief (seconds to minutes) spinning feeling that begins a few seconds after the patient assumes the triggering head position. Symptoms, which sometimes include nausea, usually resolve quickly; however, in rare cases, more sensitive patients may describe the symptoms lasting for a longer time (an hour or more). These prolonged symptoms may be due to a patient’s anxiety or a heightened individual susceptibility to nausea. Most patients whose symptoms last longer than a couple of minutes usually have a different disorder such as Meniere’s syndrome, vestibular neuritis or neurological disorder. The typical patient with BPPV then, is someone who rolls to the side in bed, or looks up or bends over and suddenly sees their surroundings moving as if spinning, lasting less than one minute.
Dix-Hallpike Test -
The clinical test for BPPV is called the Dix-Hallpike, or simply Hallpike test. The examiner turns the patient’s head halfway to the side being tested then lowers the head back a little below horizontal. After a short latency (2 to 45 secs), the eyes will typically jerk upward relative to the patient as well as torsionally for several seconds. This is assuming the crystals are in the typical “wrong” spot, namely, the lower portion of the posterior semi-circular canal. In cases of crystals in the right posterior canal, the torsional component will be counterclockwise when looking at the patient’s eyes when the head is back to the right, or clockwise if abnormal on the left side when head is tilted back to the left. BPPV typically occurs just on one side but can occur bilaterally especially after a blow to the head. It can also occur bilaterally in very old patients who first obtain crystals on one side, don’t realize it, then sometime later, obtain crystals also on the other side. The vertigo response usually “fatigues” in that a repeat of the same Hallpike movement within a minute or so may not cause any vertigo or nystagmus the second time. The response can be “hit or miss”, occurring on some occasions and not on others in the same patient. We have also seen patients who react with a positive Hallpike on the second trial but not on the first trial of the same side at the same visit. It may be that on the first trial not enough crystals had “clumped” together for a response to occur. For these reasons the disorder can seem mysterious and elusive to both patient and examiner. A negative Hallpike should not be considered proof that the patient does not have BPPV.
Recent guidelines from a multi-specialty panel recommend that patients who have symptoms of BPPV but normal Hallpike tests still should be treated with the Epley maneuver since the maneuver is easy to perform and often is effective in such cases (Otolaryngology-Head and Neck Surgery (2008) 139, S47 - S81). Also, a Hallpike response in which no eye jerking occurs but the patient feels spinning on one side, should still be taken seriously by the examiner as a sign of possible BPPV.
Epley Maneuver -
Effective recent therapies for BPPV have in recent years created a stir in the medical community owing to the success of simple maneuvers which remove the crystals from the sensitive areas. The most commonly performed and generally applicable therapy is the Epley maneuver. Other maneuvers are also used when crystals are in non-typical locations or are “stuck”. John Epley, an ENT physician, along with an audiologist colleague, created models of the ear’s semicircular canals which contained small spheres or “BBs” representing the crystals. Working with this model, certain head positions were determined which, if performed sequentially, would result in moving the offending particles back into the utricle. Although now used worldwide, the Epley maneuver was not immediately accepted by the medical community. Finally however, Epley’s method has become so popular that, nearly universally, physicians and other clinicians accept and use it successfully.
(Insert figure of Epley maneuver)
You-tube videos abound showing the Epley technique; however, the methods shown vary somewhat. There are also modifications and alternative maneuvers in use. There are several reasons why the maneuver should be performed by an experienced clinician, the most convincing of which is that it takes experience to perform the maneuver consistently and successfully. Crystals can move into other “wrong” areas if the maneuver is not performed correctly. This is not usually a serious thing, however, because crystals can usually be easily moved out of these wrong spots by experienced clinicians using alternate movements. Patients can actually feel much worse for a few minutes when crystals enter unintended areas. During the maneuver, an experienced clinician can usually tell by the direction of eye movements whether the particles are moving or have moved into the desired location, or to where they may have mistakenly moved. By watching the direction of eye movements the location of the crystals, or whether they are stuck or not, can be determined by the clinician. If crystals are in an atypical location, an appropriate alternate maneuver can be chosen to remove the crystals from these other wrong areas. Imagine the particles moving through a sort of maze, with a couple of wrong turns possible.
The Epley maneuver is not considered an “exercise” that the patient has to perform repeatedly at home, rather, the maneuver theoretically only needs to be performed once for crystals to be removed successfully. Sometimes, however, the maneuver must be performed more than once to be completely successful. Relapse of the condition at some point after the maneuver occurs in about 20% of cases.
Who Performs the Maneuver?
Training courses are available for physicians, physician assistants, audiologists, physical therapists and other professionals. While some chiropractors perform the maneuver, these “particle repositioning” maneuvers are not making adjustments to the spine, rather the head is being turned gently in various positions in order to let crystals move into the correct, non-sensitive areas. Recent “guidelines”, proposed by a committee made up of representatives from various specialties, provide recommendations about situations in which further testing is recommended (Otolaryngology-Head and Neck Surgery (2008) 139, S47 - S81).
Do it Yourself?
There are three different “semi-circular canals”, and the crystals can be in any of them, requiring different head movements to alleviate the problem. For this reason, the “take home” method is sometimes unsuccessful, with crystals ending up in just another location in the semi-circular canal areas where they may cause a different sensation of dizziness. Fortunately, when this happens, the situation can typically be corrected quickly by an experienced clinician. A majority of patients with benign positional vertigo can be cured in at most 2-3 visits, with many being cured after one treatment. There are a relatively small percentage of more stubborn cases, where crystals may be “stuck”, requiring a combination of take home exercises and in-office maneuvers. There are also rare neurological disorders which can mimic the signs of inner ear dizziness, and so this is another reason to have the situation evaluated by a professional and not try to treat the disorder yourself at home.