Benign Paroxysmal Positional Vertigo (BPPV)
Benign positional vertigo is a condition in which a person develops a sudden sensation of spinning, usually when moving the head. It is the most common cause of vertigo.
Benign positional vertigo is due to a disturbance within the inner ear. The inner ear has fluid-filled tubes called semicircular canals. The canals are very sensitive to movement of the fluid, which occurs as you change position. The fluid movement allows your brain to interpret your body’s position and maintain your balance.
Benign positional vertigo develops when a small piece of bone-like calcium breaks free and floats within the tube of the inner ear. This sends the brain confusing messages about your body’s position.
There are no major risk factors. However, the condition may partly run in families. A prior head injury (even a slight bump to the head) or an inner ear infection called labyrinthitis may make some people more likely to develop the condition.
The main symptom is a spinning sensation, which:
- Is usually triggered by head movement
- Often starts suddenly
Most often, patients say they cannot roll in bed or tilt their head up to look at something.
Other symptoms can include:
- Vision complaints, such as a perception that things are jumping or moving
- Vomiting (in severe cases)
Exams and Tests
To diagnose benign positional vertigo, the health care provider will often perform a test called the Dix-Hallpike maneuver. The doctor holds your head in a certain position and asks you to lie quickly backward over a table. As you do this, the doctor will look for abnormal eye movements and ask if you feel a spinning sensation. The doctor may use various methods to help evaluate your eye movements.
A physical exam is otherwise normal. A complete medical history and careful neurological exam should be done to rule out other reasons for your symptoms. Tests that may be done include:
- Evoked auditory potential studies
- Head CT
- Head MRI
- Magnetic resonance angiography of the head
- Warming and cooling the inner ear with water (caloric stimulation) to test eye movements
The most effective treatment is a procedure called particle-repositioning maneuvers, or “Epley’s maneuver,” which can move the small piece of bone-like calcium that is floating inside your inner ear. Other exercises that can readjust your response to head movements are less effective. You may be asked to perform exercises at home to assist with the repositioning of the floating crystals.
Occasionally, medications may be prescribed to relieve the spinning sensations. Such drugs may include:
However, such medicines often are not very effective for treating vertigo.
SURGICAL PROCEDURE FOR BPPV:
In a minority of patients with BPPV, 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. There is a risk of permanent hearing loss associated with this procedure, though this is rare.