BENIGN PAROXYSMAL POSITIONAL VERTIGO
In Benign Paroxysmal Positional Vertigo (BPPV) dizziness is generally 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”. Ear rocks are small crystals of calcium carbonate derived from a structure in the ear called the “utricle” (figure1 ). While the saccule also contains otoconia, they are not able to migrate into the canal system. The utricle may have been damaged by head injury, infection, or other disorder of the inner ear, or may have degenerated because of advanced age. Normally otoconia appear to have a slow turnover. They are probably dissolved naturally as well as actively reabsorbed by the “dark cells” of the labyrinth (Lim, 1973, 1984), which are found adjacent to the utricle and the crista, although this idea is not accepted by all (see Zucca, 1998, and Buckingham, 1999).
BPPV is a common cause of dizziness. About 20% of all dizziness is due to BPPV. While BPPV can occur in children (Uneri and Turkdogan, 2003), the older you are, the more likely it is that your dizziness is due to BPPV. About 50% of all dizziness in older people is due to BPPV. In one study, 9% of a group of urban dwelling elders were found to have undiagnosed BPPV (Oghalai et al., 2000).
The symptoms of BPPV include dizziness or vertigo, lightheadedness, imbalance, and nausea. Activities which bring on symptoms will vary among persons, but symptoms are almost always precipitated by a change of position of the head with respect to gravity. Getting out of bed or rolling over in bed are common “problem” motions . Because people with BPPV often feel dizzy and unsteady when they tip their heads back to look up, sometimes BPPV is called “top shelf vertigo.” Women with BPPV may find that the use of shampoo bowls in beauty parlors brings on symptoms. A Yoga posture called the “down dog”, or Pilates are sometimes the trigger. An intermittent pattern is common. BPPV may be present for a few weeks, then stop, then come back again.
In half of all cases, BPPV is called “idiopathic,” which means it occurs for no known reason.
The Epley maneuver is also called the particle repositioning or canalith repositioning procedure. It was invented by Dr. John Epley, and is illustrated in figure 2. It involves sequential movement of the head into four positions, staying in each position for roughly 30 seconds. The recurrence rate for BPPV after these maneuvers is about 30 percent at one year, and in some instances a second treatment may be necessary.
1. Wait for 10 minutes after the maneuver is performed before going home. This is to avoid “quick spins,” or brief bursts of vertigo as debris repositions itself immediately after the maneuver. Don’t drive yourself home.
2. Sleep semi-recumbent for the next night. This means sleep with your head halfway between being flat and upright (a 45 degree angle). This is most easily done by using a recliner chair or by using pillows arranged on a couch (see figure 3). During the day, try to keep your head vertical. You must not go to the hairdresser or dentist. No exercise which requires head movement. When men shave under their chins, they should bend their bodies forward in order to keep their head vertical. If eyedrops are required, try to put them in without tilting the head back.
Be careful to avoid head-extended position, in which you are lying on your back, especially with your head turned towards the affected side. This means be cautious at the beauty parlor, dentist’s office, and while undergoing minor surgery. Try to stay as upright as possible. Exercises for low-back pain should be stopped for a week. No “sit-ups” should be done for at least one week and no “crawl” swimming. (Breast stroke is OK.) Also avoid far head-forward positions such as might occur in certain exercises (i.e. touching the toes). Do not start doing the Brandt-Daroff exercises immediately or 2 days after the Epley or Semont maneuver, unless specifically instructed otherwise by your health care provider.
HOME EPLEY MANEUVER
The Dix-Hallpike test (figure to right shows how to test the right ear)
The figure to the right illustrates the Dix-Hallpike test. In this test, a person is brought from sitting to a supine position, with the head turned 45 degrees to one side and extended about 20 degrees backward. A positive Dix-Hallpike tests consists of a burst of nystagmus (jumping of the eyes). The eyes jump upward as well as twist so that the top part of the eye jumps toward the down side.
The Epley and/or Semont maneuvers as described above can be done at home (Radke et al, 1999; Furman and Hain, 2004). We often recommend the home-Epley to our patients who have a clear diagnosis. This procedure seems to be even more effective than the in-office procedure, perhaps because it is repeated every night for a week.
The method (for the left side) is performed as shown on the figure to the right. One stays in each of the supine (lying down) positions for 30 seconds, and in the sitting upright position (top) for 1 minute. Thus, once cycle takes 2 1/2 minutes. Typically 3 cycles are performed just prior to going to sleep. It is best to do them at night rather than in the morning or midday, as if one becomes dizzy following the exercises, then it can resolve while one is sleeping. The mirror image of this procedure is used for the right ear.
There are several problems with the “do it yourself” method. If the diagnosis of BPPV has not been confirmed, one may be attempting to treat another condition (such as a brain tumor or stroke) with positional exercises — this is unlikely to be successful and may delay proper treatment. A second problem is that the home-Epley requires knowledge of the “bad” side. Sometimes this can be tricky to establish. Complications such as conversion to another canal (see below) can occur during the Epley maneuver, which are better handled in a doctor’s office than at home. Finally, occasionally during the Epley maneuver neurological symptoms are provoked due to compression of the vertebral arteries. In our opinion, it is safer to have the first Epley performed in a doctors office where appropriate action can be taken in this eventuality.
The manuever starts sitting upright . This maneuver should be done by your doctor or physical therapist both for safety (you may be dizzy) and to observe the eye movements.
2. First, your doctor will have you briskly lie on your back with your head turned to the symptomatic side at a 45 degree angle. This picture illustrates a treatment of the right side. Your head will be kept in this position for 30 to 60 seconds, based on the duration of the vertigo as measured by observation of your eye movements (for nystagmus). You will probably be dizzy for the first 10 seconds.
4. Finally, your doctor will have you roll in the same direction onto your side, carrying your head along so that it is pointed about 45 degrees, nose down. This position is also maintained for 30 seconds, and another burst of dizziness may occur.
5. Finally, you are returned to sitting. It is common to be very dizzy at this point for about 15 seconds, and your doctor or therapist will be available to steady you. Remain with the head tilted a bit down (as shown) for one minute. Then, the entire maneuver is repeated for two more repetitions.