BPPV is a common cause of vertigo
Benign paroxysmal positional vertigo (BPPV) is the most common form of spinning dizziness (vertigo) originating from the ear (1, 2). It is estimated that 10% of people above 65 years will at least get one spell in their lifetime. 50% of all dizziness in older patients is due to BPPV. It is slightly more common in female patients and infrequent in children. In males, it is often related to previous trauma. It occurs more on the right side as people tend to sleep more on the right side. It may involve both sides. The posterior canal is most often involved in 85% to 90% of cases, the horizontal in 8% to 10% and the superior in less than 2%. More than one canal can be involved, and it may change from one canal to another. BPPV is the most common cause of peripheral positional nystagmus. Positional nystagmus can also be elicited in central neurological disorders.
Causes of BPPV
The following may cause BPPV:
- Unknown – 60%
- After whiplash, head and neck trauma – 18%
- Virus infections of the inner ear
- Bloodflow impairment to the inner ear
- After any surgery, toxic medication to the ear, ear infections, possible Vitamine D deficiency and Menière’s disease (3)
Mechanism of BPPV
The most acceptable explanation is that some of the calcium carbonate crystals (otoconia) of the inner ear’s balance organ (utricle) become loose or dislodged and then move into one of the semicircular canals by mistake (4). When enough of these otoconia enter the canal, they can clot together, and this clot or rock can then create the symptoms due to inappropriate stimulation.
In the semicircular canal, the otoconia most often float in the canal (canalithiasis) but can also adhere to the cupula (cupulolithiasis). It can also change from cupulolithiasis to canalithiasis and vice versa. When the patient keeps still, the otoconia stops moving, and the symptoms disappear until the head is moved again. Sometimes, the clot can break up, and the otoconia absorbs, or they can spontaneously move back to the utricle, and then the symptoms disappear for a more extended period.
Another possible explanation is that a virus can affect the nerves of the semicircular canals, leading to misfires and inappropriate signals during head movements, which can cause symptoms.
Symptoms of BPPV
Symptoms of BPPV may include:
- Spinning dizziness (vertigo)
- Balance impairment
- Lightheadedness, floating sensation, difficulty walking and nausea.
- Blurring of vision
- Hearing is usually not affected
Due to the variety of symptoms, all patients with dizziness should be tested for BPPV.
The classical presentation of BPPV
The classical presentation of benign paroxysmal positional vertigo (BPPV) is the sudden onset of severe spinning dizziness (vertigo) triggered by a change in head position. It can occur when a patient turns over in bed, looks up or down, turns around or performs any other head movement. It is more common in the morning, after a night’s sleep. The patient is often nauseous. The vertigo is accompanied by abnormally fast, repetitive jerking eye movements (nystagmus). The vertigo is short and lasts only a few seconds. It is better when the head is kept still but occurs again if it is moved. BPPV is often triggered by a specific head movement such as turning to one side. Patients, therefore, usually choose only to sleep on the back or a particular side and move as little as possible during the night. It can last for days to weeks and then disappear by itself. It recurs in 30% to 50% of patients. When a patient gets an attack, loss of balance can lead to falls and injuries.
BPPV diagnosis
BPPV is a clinical diagnosis (5). Posterior canal BPPV is diagnosed with either the Dix Hallpike or Semont side-lying test (6,7, 8). The clinical examination aims to elicit the symptoms and demonstrate abnormal involuntary repetitive eye movements (nystagmus). The type and direction of the nystagmus determine whether it is true BPPV of the ear or whether it is central and originating in the brain. The nystagmus also identifies the canal involved and the localisation of the loose otoconia.
Central BPPV is a less common form of BPPV that is caused by a dysfunction in the central nervous system rather than the inner ear. It can be caused by issues such as head trauma, drugs, migraines, or neurological disorders. Symptoms include dizziness and balance problems but the examination is usually not typical for peripheral BPPV.
Special investigations include videonystagmoscopy, videonystagmography (VNG) and magnetic resonance imaging (MRI). MRI is performed to exclude brain or central conditions that may mimic BPPV or if atypical BPPV is present. There may be no symptoms when seeing the doctor, and the examination may be normal, but this does not exclude BPPV.
BPPV management
The management of benign paroxysmal positional vertigo (BPPV) includes lifestyle modification, medication, manoeuvres, exercises and surgery.
Lifestyle modification means that the patient should avoid the movements or positioning of the head that elicits the symptoms. This approach is not practical in the long run.
BPPV is a mechanical disorder. Medication is of little help and cannot prevent or cure BPPV. Medication may reduce symptoms temporarily, especially when performing the manoeuvres.
Specific exercises like the Brandt and Daroff exercises may benefit some patients where more than one canal is involved or where the manoeuvres are unsuccessful. It’s real efficacy is debated.
BPPV manoeuvres
Manoeuvres are specifically designed movements that aim to cure BPPV (8). A medical doctor or trained professional should ideally perform it. In many cases, patients can be taught how to perform the manoeuvres on themselves safely.
About 50% of BPPV will spontaneously resolve without intervention in one month and about 90% in three months. The manoeuvres aim to shorten the duration of the symptoms
The manoeuvre replaces the displaced otoconia (crystals) out of the canals and return them to the utricle of the inner ear or loosen it from the cupula. There are different manoeuvres for the various canals. Performing a wrong manoeuvre will not be effective.
Some of the many manoeuvres include the Epley manoeuvre, Parnes manoeuvre, Semont manoeuvre, Aprella manoeuvre, Guffoni manoeuvre, Log roll, BBQ rotation and other variants (9,10).
Dr Hofmeyr personally prefer the Semont Plus manoeuvre, Log roll and modified Yacovinio manoeuvre (11).
After a successful manoeuvre or exercise program, BPPV can recur in 30%- 50% of patients.
Surgery for BPPV
Surgery can be performed when all the above fail (12,13). It is seldom necessary and performed in less than 5% of all the patients seen with BPPV. The canal causing the symptoms must be positively identified with the examination on more than one occasion. The abnormal involuntary repetitive eye movements (nystagmus) must ideally be recorded before surgery. Surgery should be restricted to one canal.
BPPV is not a life-threatening condition but does impair functioning and quality of life. In many cases, it can lead to psychological problems and depression in patients.
Patients may also be at risk of when becoming dizzy, losing their balance, falling and injuring themselves and others during an attacks
The different surgical procedures for BPPV
Surgery can either be performed through the mastoid (back of the ear) or the middle ear by lifting the eardrum.
The two types of operations are:
- Fenestration and occlusion of a semicircular canal (FOS)
- Singular neurectomy (SN)
Dr Hofmeyr’s experience
Dr Hofmeyr has managed more than 1000 patients with BPPV and has performed successful surgery on numerous patients.
He is currently the only surgeon who performs surgery for BPPV on a regular basis.