Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo or BPPV causes dizziness due to abnormalities in the inner ear. The inner ear has small sensory structures called hair cells that are embedded in a soft structure containing crystals of calcium carbonate called otoliths or otoconia. The soft structure sometimes fragments or loosens allowing the otoconia to become free in the balance portion of the inner ear. They fall or are moved on to other structures, creating abnormal perceptions of balance.

 

The symptoms of positional vertigo can include dizziness, spinning, lightheadedness, imbalance and nausea. Activities that bring on the symptoms will vary but almost always caused by a position change of the head. Getting out of bed or rolling over in bed are common motions that bring on dizziness. Because people with benign paroxysmal positional vertigo often feel dizzy and unsteady when they tip their head back to look up, sometimes BPPV is called top shelf vertigo. Individuals who experience the symptoms often find that when the symptoms begin their problems are more severe, but over time they tend to resolve on their own. While no one knows what really causes BPPV, some individuals had head trauma just before the symptoms appeared. Even a violent rapid movement of the head such as whiplash can cause BPPV. The diagnosis can be established by examining a patient's eye movements during specific head motions. This will allow your doctor to determine which ear is causing the symptoms. Sometimes both ears are abnormal. Other doctors feel that history alone may be sufficient. Many individuals experience symptoms particularly when they go to bed or get up in the morning. Avoiding a completely flat position sometimes can resolve problem. Individuals who sleep with a slight head up position find that their symptoms are less severe. Lights and firm surfaces minimize problems.

Treatment

Benign positional vertigo is often self-limiting and symptoms can subside within several months. The symptoms tend to wax and wane without apparent reason. Motion sickness medications sometimes help but can prolong the recovery period. There is physical therapy involving head and body maneuvers or exercises that have been proven to be effective.

Epley maneuver

A physical therapist can be trained in the use of the Epley maneuver. The Epley maneuver involves sequentially moving the head in several different positions. The recurrence of symptoms following treatment is relatively low, about 5 to 10 percent, and in some instances multiple treatments are necessary. After you undergo the Epley maneuver it should be noted that you should avoid rapid movements that could reposition the otoconia. The Epley is thought to place otolithic debris into a portion of the inner ear where they do not cause symptoms. Most therapists recommend that you sleep in slightly upright position for approximately two or three days. During this period of time you may not move your head quickly side to side. Vigorous exercise should be avoided during this period of time. After approximately a week, patients may resume most activities but should do so gradually.

Surgical treatment

If the Epley maneuver is ineffective, there are other surgical options for treatment. Those individuals who have proven benign paroxysmal positional vertigo can consider surgical procedures such as a vestibular nerve section, canal obstruction procedure, singular nerve section or other operations.

Vestibular nerve section

Vestibular nerve section is an operation designed to cut the balance nerve of one ear. The theory is that if the balance function is eliminated from the problem side, symptoms will disappear over a longer period of time. The brain can adapt to no information, but it cannot handle incorrect information. The vestibular nerve section is performed by making an incision directly behind the ear. The incision extends down into the neck and an opening is created into the skull. By separating the area between the brain and the temporal bone that houses the inner ear, the surgeon can identify the vestibular nerve as it enters into the inner ear. The nerve is then cut. Most individuals experienced one last severe experience of dizziness. Recovery can take up six months. Since the hearing nerve is next to the balance nerve, there is a small risk of hearing loss. Other risks are extremely rare.

Canal obstruction procedures

A canal obstruction procedure is generally shorter in duration and involves less risk. The operation is done through the mastoid bone directly behind the ear. An incision is made in the crease behind the ear and some of the bone is removed. After entering the area near the inner ear, the surgeon identifies the posterior semicircular canal which is part of the balance portion of the inner ear. This canal is usually the offending semicircular canal. The surgeon then opens a segment of bone housing the canal and plugs it with ground up bone and muscle. This prevents fluid from moving in this segment of the semicircular canal. Patients often experience one relatively mild attack of dizziness following the procedure and then have complete resolution of their symptoms. Sometimes, because of injuries to the membranes or because the bone is forced into other segments of the ear, patients may experience hearing loss. Perhaps a third of those individuals who undergo the operation will experience permanent complete hearing loss.

Singular nerve section

Dr. Richard Gacek introduced the singular nerve section in the 1960s. The operation has fallen out of favor recently because of its 20% hearing loss (deafness) rates. Most individuals who experienced hearing loss had no functional hearing left in the operated ear. The advantage is that those individuals who have success from the operation are almost immediately cured. Many can go home the same day. Some individuals experience dizziness and have to be hospitalized briefly following the procedure. Other complications such as facial weakness are extremely rare.

Conclusion

There is no reason for someone with benign paroxysmal positional vertigo to suffer permanently. It is uncommon for individuals with BPPV to be permanently disabled by their condition. Most people who have this can eventually experience improvement in their symptoms.