Benign Paroxysmal Positional Vertigo (BPPV)
What Is BPPV?
Benign Paroxysmal Positional Vertigo (BPPV) is a common disorder of the vestibular system characterised by brief (less than a minute) episodes of dizziness/vertigo.
It is thought to be due to debris which has collected within a part of the inner ear. This debris can be thought of as "ear rocks", although the formal name is "otoconia", which are small crystals of calcium carbonate derived from a structure in the ear called the "utricle".
One of the main roles of the Inner ear is to monitor head position and movement in space and relay that information the brain to help us with our balance. In this area there are 3 (semicircular) canals filled with fluid that move and respond to movement. When this flow is interrupted by the otoconia it results in abnormal information being relayed to the brain and results in bouts of vertigo.
Who Does It Affect?
Although BPPV can occur at any age, it is most often seen in people over the age of 60. The older you are, the more likely it is that your dizziness is due to BPPV, as about 50% of all dizziness in older people is due to BPPV. It is also more common in females than males.
What Is the Cause?
BPPV is one of the most common vestibular disorders in patients presenting with dizziness. Besides aging, there are no major risk factors known for developing BPPV, although previous episodes of trauma to the head or inner ear infections, may predispose individuals to future development of BPPV. Other Causes include:
· BPPV has an association with migraines
· Degeneration of the inner ear vestibular system – most common cause in older people
· Viruses affecting the ear
· Minor strokes
· Post surgery or prolonged dental work
How Does It Occur?
In patients with BPPV, the otoconia are dislodged from their usual position within the utricle and 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 ("ear rocks") within the affected semicircular canal causes abnormal (pathological) fluid displacement and a resultant sensation of vertigo.
In some cases, the crystals themselves can adhere to a semicircular canal cupula (similar to a hair) rendering it heavier than the surrounding fluid. 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 nerves à vertigo.
The vertigo can be triggered by any action which stimulates the posterior semi-circular canal including tilting the head, rolling over in bed, looking up or a sudden head motion.
BPPV can be made worse by changes in barometric pressure - patients often feel symptoms approximately two days before rain or snow, Lack of sleep or stress.
What Are the Symptoms?
· Dizziness or vertigo of short duration (paroxysmal): Lasts only seconds to minutes
· Light-headedness or imbalance
· Visual disturbances
· Feeling faint
· Vomiting is uncommon but possible.
Activities which bring on symptoms will vary among people, but symptoms are almost always precipitated by a change of position of the head with respect to gravity, common activities include:
· Getting out of bed or rolling over in bed (differentiates between postural problems)
· “Top Shelf Vertigo” feeling of being dizzy and unsteady when tipping head to look up.
· Symptoms may be provoked when getting hair washed at the hairdresser or when having dental work done
· Men may have difficulty with shaving under chin
· An intermittent pattern is common, i.e. it may be present for a few weeks, then stop, and come back again.
The clinical sign of BPPV is a rotatory (torsional) nystagmus, where the top of the eye rotates towards the affected ear in a beating or twitching fashion. Nystagmus should only last for 30 seconds to one minute.
Clinical diagnosis is made based on findings from the physical examination. These include a specific series of tests which first exclude other, more sinister, causes of dizziness, followed by a positive Dix Hallpike test if BPPV is suspected.
In this test a person is brought from sitting to a lying position, with the head turned 45 degrees to one side and extended about 20 degrees backward.
Once supine, the eyes are typically observed for about 30 seconds. If no nystagmus ensues, the person is brought back to sitting. There is a delay of about 30 seconds again, and then the other side is tested.
A positive test consists of a burst of nystagmus (jumping of the eyes). In classic posterior canal BPPV, the eyes jump upward as well as twist so that the top part of the eye jumps toward the down side.
BPPV is described as "self-limiting" because symptoms often subside or disappear within six months of onset. Symptoms tend to wax and wane. Motion sickness medications are sometimes helpful in controlling the nausea associated with BPPV but are otherwise rarely beneficial. However, various kinds of physical manoeuvres and exercises have proved effective.
In our clinic the treatment most often used is Epleys manoeuvre, it is incredibly effective (much better than motion sickness tablets) and relieves symptoms in around 80% of patients. It is intended to move the debris out of the sensitive part of the ear (posterior canal) to a less sensitive location. It involves sequential movement of the head into four positions, staying in each position for roughly 30 seconds.
After this manoeuvre, your therapist will give you a specific set of instructions which are aimed at reducing the chance that debris might fall back into the sensitive back part of the ear and whilst effective, sometimes a reoccurrence is experienced, and the manoeuvre will need to be repeated.
So that’s a brief overview of BPPV and how and why it occurs, If you have questions or comments feel free to e-mail us at firstname.lastname@example.org and we will be happy to answer them for you.
If you think you may already be suffering from BPPV, then addressing it sooner rather than later is crucial. We often see clients who have had vertigo for months, with no relief from medication who respond very quickly to the repositioning treatment. So, if you want relief now, call us on (08) 9486 8653 and we will arrange an appointment for you.