Introduction

Benign Paroxysmal Positional Vertigo (BPPV) is an inner ear problem that results in short lasting, but severe, room-spinning vertigo. Its name, BPPV, indicates that it is benign, or not a very serious or progressive condition; paroxysmal, meaning sudden and unpredictable in onset; positional, because it comes about with a change in head position; and vertigo, causing a sense of room-spinning or whirling. Although called benign, those who suffer from this distressing and incapacitating condition do not trivialize BPPV.

Clinical Symptoms

This condition develops following trauma or a severe cold. It can also develop as part of the aging process. It is sudden in onset and usually first noticed in bed, when waking from sleep. Any turn of the head seems to bring on violent but brief bursts of dizziness. In many cases, nausea and vomiting also accompanies the vertigo. There is no new hearing loss or severe ringing associated with these attacks, which distinguishes it from other inner ear conditions. Even if a spell is brief, a feeling of queasiness may last several minutes to hours. Patients often describe the occurrence of the vertigo with tilting of the head, looking up or down, or rolling over in bed.

Cause

It has been discovered that the probable cause of BPPV is dislodgement of normal, small calcium carbonate crystals that float through the inner ear fluid and strike against sensitive nerve endings within the balance apparatus. These crystals, known as otoconia, usually settle down within several weeks, and no longer cause any symptoms.

However, in some patients, these crystals become trapped in the fluid of the balance chamber and periodically cause symptoms, as gravity causes them to repeatedly strike against the nerve endings. In these patients, the symptoms may not subside and they become severely incapacitated.

Diagnosis

The most important element for the successful diagnosis of this condition is the physical examination and history of the patient. The description of the dizziness/vertigo without hearing problems point to the diagnosis of BPPV. A normal ear exam, audiogram, and neurological exam are expected. It is when the patient is put through a series of positional tests, such as the Dix-Hallpike Test, that sudden reproduction of symptoms occur. When the ear causing the symptoms is placed undermost or dependent, rotary eye movements, know as nystagmus, begin after several seconds.

This nystagmus and perception of vertigo will slow down and cease after 15 to 20 seconds. If the head is not moved, no further symptoms will occur. When the patient sits back up, the dizziness will recur, but for a shorter period of time. Lying down on the opposite side will not cause the vertigo. Occasionally, in order to confirm the extent of the inner ear dysfunction, an electronystagmogram (ENG) will be ordered. At the conclusion of a positive positioning test, the examiner will usually know which ear is affected.

Treatment

Once tests have confirmed the diagnosis of BPPV and the affected ear, patients are instructed to avoid lying down on the affected side. Usually, medications like Antivert® (meclizine), Dramamine®, Valium®, or Phenergan® are not recommended because they cause sedation. By carefully avoiding the provocative position, patients can usually avoid bringing about the symptoms. If left untreated, the condition clears within several weeks.

Recently, researchers have found that a simple and well-tolerated physical therapy technique performed in the office can relieve the vertigo in a high percentage of patients. The Otolith Repositioning procedure of Semont and Epley has become well accepted and is based on using gravity to move the crystals away from the nerve endings into an area of the inner ear that won’t cause any problems. Sometimes, a vibrator is placed on the mastoid to "liberate" the particles and increase success of the procedure.

In our experience, approximately 75% of patients are cured with one maneuver. This percentage increases with repeated treatments. Following the maneuver, patients must not lie flat for 48 hours, meaning they should sleep in a recliner or propped up on pillows. Also, after 48 hours, patients should not lay down on the affected ear for at least one week following the treatment. These instructions help prevent the crystals from falling back into the balance chamber. Even tying shoes or bending over should be avoided during this week.

Surgical Treatment

Rarely, when time and the otolith repositioning techniques have failed, patients considered the very worst cases will require surgical intervention. The following are several procedures worth mentioning.

Singular Neurectomy (or Posterior Ampullar Nerve Section)

A tiny branch of the balance nerve travels through a bony canal before it reaches the nerve endings of the balance canal. The goal of this surgery is to expose the canal through the ear and to cut this tiny nerve so when the crystals strike the nerve endings, no symptoms develop because this information no longer reaches the brain. In experienced hands, this surgery is safe and relieves the symptoms permanently. In a small percentage of cases, the nerve is located in an unreachable spot and cannot be safely cut during surgery. In these cases, no improvement is achieved. In a few patients, hearing loss, tinnitus, and dizziness can result from the surgery.

Posterior Canal Plugging Procedure

This is a recently developed procedure that has nearly replaced the singular neurectomy due to its ease. In this procedure, a mastoidectomy is performed through an incision made behind the ear. The balance center is then uncovered and the posterior semicircular canal is opened, exposing the delicate membranous channel in which the crystalline debris is floating. The canal is then gently, but firmly packed off with tissue so the debris can no longer move within the canal and strike against the nerve endings. The canal is then sealed and the incision closed.

Most patients will be somewhat dizzy the first night, so a one-night hospital stay is advised. The patient returns in one week for suture removal. Because of blood and swelling, hearing loss and some dizziness may last several weeks. Medication is prescribed to minimize this and prevent complications. The acute vertigo from BPPV is cured in the majority of cases. The exact percentage of patients with some permanent hearing loss has not yet been firmly established. However, it has been reported to be less than 20% in early studies.

Vestibular Nerve Section (or Neurectomy)

In some cases, when positional vertigo is quite severe and hearing is still normal, testing reveals that this is not due to crystalline debris floating in the canal, but due to a severely damaged balance nerve. In such cases, the previous two procedures would not relieve the symptoms. Instead, the entire balance nerve is sectioned to prevent this distorted information from reaching the brain. In successful cases, after an initial period of several weeks, the original dizziness and any dizziness caused by the surgery, gradually disappears and no future vertigo can occur from that diseased ear. In this operation, a neurosurgeon on the operating team exposes the nerve as it crosses from the ear to the brain, then sections the nerve under direct view with an operating microscope. Both the hearing nerve and facial nerve are monitored to prevent their inadvertent injury. In some cases, high frequency hearing loss and injury can occur because the balance nerve fibers and hearing fibers mix along the border where these two branches merge together as the single 8th Cranial Nerve and cannot be physically avoided.

Several days of hospitalization is customary. Risks include hearing loss, tinnitus, facial nerve weakness, spinal fluid leakage, and meningitis. These serious complications are extremely rare, but should be recognized by the patient prior to agreeing to proceed with surgery.

Comments

No patient with disabling vertigo should suffer needlessly. If dizziness does not disappear over time with medication or with the physical therapy techniques described above, surgical therapy may be an option and should be discussed with your physician.