Benign Paroxysmal Positional Vertigo

Overview

Vertigo is a sensation or feeling that you or everything around you is spinning, tilting or swaying. This sensation can be enough to make you lose your balance, lasting anything from a few seconds to hours. It is beyond just feeling ‘dizzy’ - a term which can often mislead diagnosis, and in severe cases, this can last for days or months.

Vertigo can be divided into two types: central vertigo (caused by issues with the central nervous system) and peripheral vertigo (issues with the part of the inner ear that deals with balance). Benign Paroxysmal Positional Vertigo (BPPV) is the most common type of peripheral vertigo, accounting for more than half of reported cases.

Background

BPPV was first described in 1921. However, it wasn’t until 1952 that Dix and Hallpike explained the location of the pathology as positional vertigo in fluid-filled canals of the inner ear.¹ Paroxysmal Positional Vertigo (BPPV) occurs when small calcium crystals (otoconia) located in the inner ear become dislodged and end up in the semicircular canals, which are responsible for maintaining balance.

Benign Paroxysmal Positional Vertigo (BPPV) is a disorder that causes issues with balance, affecting the inner ear and causing brief episodes of vertigo. BPPV is characterized by sudden and intense spinning sensations that are triggered by changes in head position, such as turning over in bed or looking up. The severity and frequency of symptoms can vary depending on the individual, with episodes typically lasting for less than a minute; however, these symptoms can be debilitating for some people, leading to nausea, vomiting, and difficulty with daily activities.

The ear and BPPV and its types

The ear is divided into three sections:²

• The outer Ear: The part of the ear that we can see, as well as the outer canal you can see into. The outer ear collects sound waves for them to be amplified further within the ear. The outer ear also prevents insects and other objects from entering the ear.
• The middle Ear: Separated from the outer ear by the tympanic membrane (eardrum), the middle ear is split into two sections, the tympanic chamber and the epitympanic chamber. The tympanic chamber is involved in amplifying sound waves from the outer ear to the inner ear while the epitympanic chamber regulates pressure within the ear.
• The inner Ear: Composed of three parts, the cochlea, semicircular canals and the vestibule. The Cochlea receives sound waves via vibrations from the middle ear before sending signals to the brain via the auditory nerve. The semicircular canals and the vestibule (vestibular system) are involved in balance and sensing orientation changes. 

BPPV and the vestibular system 

The vestibular system plays an essential role in our ability to maintain balance, spatial orientation, and coordination. It is responsible for detecting changes in position and movement of the head and body; transmitting this information to the brain.

The semicircular canals are filled with fluid and lined with tiny hairs. Changes in balance or orientation cause the fluid to move, which is detected by the tiny hairs, sending signals to the brain about the changes. 

The vestibule is also involved in balance and orientation, containing fluid, tiny hairs and crystals called otoconia that are involved in detecting changes in acceleration and gravity. These crystals may become loose, breaking off from the Each ear has three semicircular canals, the superior, lateral and posterior canals, and each forms two-thirds of a full circle.³

Posterior semicircular canal (PSCC)

Classification of BPPV is based on the anatomical location, the semicircular canal which is in the posterior location is most commonly involved in BPPV (80%).

Lateral (horizontal) canal (LSCC)

The incidence of LSCC is around 10-12%, making it the second most common type of BPPV. LSCC occurs due to detached otoconia that enters the lateral canal instead of the posterior canal. Vertigo in individuals affected may be more intense than in posterior canal involvement.

Anterior (superior) canal (SSCC)

Anterior canal BPPV is considered the rarest form with a postulated frequency of 2-5% of cases.

Causes and contributing factors 

Primary or idiopathic BBPV cases account for around 50 -70% of BPPV cases with an unknown cause.⁴ All other cases of BPPV are referred to as secondary BPPV as they are often associated with an underlying cause, such as

• Head trauma
• Migraines
• Complications post-surgery or from medications
• Ménière disease is a condition affecting the inner ear that can cause vertigo, tinnitus, hearing loss, and a feeling of pressure in the ear caused by fluid imbalance in the inner ear.
• Labyrinthitis - causes inner ear inflammation, leading to vertigo and hearing loss.
• Vestibular neuronitis - similar to labyrinthitis in that it is an inner ear inflammatory infection that affects balance but does not affect hearing

Up to 17% of secondary BPPV cases are a result of head injuries, making it the most common cause, although secondary BPPV has also been reported in numerous cases following inner ear surgery. 

Who is at risk?

Although it can occur at any age, the highest incidence of primary or idiopathic BPPV has been observed from ages 50 to 70 years. In patients under 35 years old, it is seldom detected without a prior history of head injury.

Signs and symptoms

The most common symptom of BPPV is vertigo, and the sensation ranges from mild to severe at different lengths. Other symptoms experienced include;

• Balance issues
• Nausea 
• Lightheadedness
• Vomiting
• Blurred vision
• A feeling of pressure in the inner ear
• Nystagmus (rapid involuntary eye movements)

Symptoms may vary between individuals depending on the underlying cause of BPPV.

Diagnosis

The Dix-Hallpike manoeuvre is the only standard clinical test for BPPV. The test involves swiftly moving the patient from a sitting to a supine position (lying down) with the head turned 45 degrees. The healthcare provider will observe the patient's eyes for 20 to 30 seconds, and if there is no nystagmus the patient is brought back to the sitting position and the maneuver is repeated on the opposite side.⁵

In some instances, imaging tests such as an MRI or CT scan may be done to rule out other possible causes of vertigo.

Treatment

The first line of treatment for posterior canal BPPV is a repositioning manoeuvre intended to clear the affected semicircular canal of any debris. The manoeuvre is called the particle repositioning manoeuvre (PRM) and has many variants,  such as the Semont manoeuvre, the Epley manoeuvre, and the 3-position manoeuvre. These manoeuvres involve a doctor moving your head in a series of head movements to help move the dislodged otoconia from the semicircular canals.⁶ 

The majority of BPPV patients will see their symptoms resolved completely through the use of repositioning manoeuvres. However, the manoeuvres can sometimes bring forward adverse effects, such as:

• Conversion of posterior BPPV to a lateral or anterior canal BPPV during a manoeuvre
• Vomiting
• Imbalance

Patients should be aware that recurrences are common even after successful management with repositioning manoeuvres so that further treatment may be necessary.

Medication

• Antihistamines (meclizine) - address vertigo by suppressing labyrinth excitability and vestibular end-organ receptors. Prescribed in cases of high-frequency vertigo spells disruptive to daily life. 
• Nausea and vomiting symptoms can be treated with anti-emetics as needed.

​​Surgical intervention

Surgical intervention is reserved for more unmanageable cases of BPPV, and there are two options: singular neurectomy and posterior canal occlusion. Posterior canal occlusion is the recommended choice as it has proven to be highly effective and safe.

Summary

Benign Paroxysmal Positional Vertigo (BPPV) is a very common type of peripheral vertigo that can occur at any age, accounting for more than half of reported cases. BPPV can be caused by several factors, such as head trauma, migraines or complications following surgery with a presentation of symptoms including, but not limited to, vomiting, blurred vision, or a feeling of pressure in the inner ear.

Diagnosis of BPPV is carried out using the Dix-Hallpike maneuver; or in severe cases, an MRI or CT scan may be conducted to rule out other causes of symptoms. Initial steps in the management of BPPV should include patient education and counselling. Treatment options vary from positional maneuvers to medication or surgery depending on the severity and cause of symptoms.