Introduction

Definition of vertigo 

Vertigo is defined as the perception of movement of the body or the environment in the absence of actual movement. 

The underlying cause of vertigo could be peripheral (in the ear) or central (in the brain).

Benign Paroxysmal Positional Vertigo (BPPV)

BPPV is the most frequent cause of peripheral vertigo. It causes recurrent attacks of vertigo that are short-lived–lasting seconds–and is provoked by certain head positions. BPPV is a self-limiting condition that is usually treated with simple repositioning methods. 

BPPV is either:

• Primary BPPV: occurs without an underlying pathology (condition or disease), it is more common, accounting for 50-70% of cases¹
• Secondary BPPV: occurs in association with an underlying pathology, such as head trauma, migraine, ischemia, or labyrinthitis¹

Malignant Paroxysmal Positional Vertigo (MPPV)

MPPV is a less common cause of recurrent attacks of vertigo caused by brain lesions such as multiple sclerosis, metastatic lesions, or vascular lesions. MPPV usually does not respond to repositioning methods and requires a neurological consultation. 

To differentiate between BPPV and MPPV, the doctor performs a manoeuvre called the Dix-Hallpike manoeuvre. During this manoeuvre, the patient is instructed to sit on a couch, turn their head 45 degrees toward the examiner, and take their head backwards into the provocating position. The eyes should be kept open focusing on the examiner's eyes or forehead. 

Other methods might be needed to establish the diagnosis, such as performing an otoscopy, audiometry, or neuroimaging with MRI. 

The main focus of this article is BPPV and its recurrence. 

Importance of understanding recurrence and prolapse in PPV

Given that the recurrences of BPPV are frequent, it is important for both, the physician and the patient, to anticipate BPPV recurrence. The annual recurrence rate of BPPV after successful repositioning manoeuvres is 15–20%.²

Background Information

Epidemiology of PPV

BPPV is the most common cause of vertigo worldwide. Becoming more common with advanced age. It is also more common in people assigned female at birth (AFAB), with female-to-male ratio of 2.4:1.³

Pathophysiology of PPV 

The main pathological mechanism of BPPV is the detachment of particles (called otoconia) composed of calcium-carbonate crystals found in the canals of the inner ear from their place.  This detachment will cause these particles to be displaced via the effect of gravity, inducing short-duration paroxysmal vertigo mainly when lying in bed in a specific head position.

Initial Symptoms and Diagnosis

Common symptoms

BPPV is usually suspected when there are recurrent short-lived attacks of vertigo, that could be associated with nausea or vomiting, in the absence of hearing loss and tinnitus (buzzing sound in the ear). 

Diagnostic tests

The diagnosis of BPPV can be confirmed by performing a manoeuvre called the Dix-Hallpike manoeuvre. This manoeuvre triggers nystagmus, an involuntary rapid eye movement reflecting vertigo. 

The Dix-Hallpike manoeuvre is performed by asking the patient to rapidly move from a sitting to a lying position, with the head turned 45 degrees to the right at first, after 20 to 30 seconds, we bring the patient back to the sitting position, and we watch for any nystagmus. If no nystagmus is produced, the same procedure is repeated on the left side.¹

Treatment 

BPPV may resolve spontaneously, however, it is advisable that the condition be treated with repositioning manoeuvres, called canalith repositioning therapy (CRT). Multiple manoeuvres can be used, such as Epley’s manoeuvre, which involves a series of movements that aim to reposition the particles in the inner ear into their normal place. 

Complete recovery after a single manoeuvre is achieved in about 50–60% of the patients, and in more than 90% after repetitive maneuvers.⁴

Some medications can also be used to treat the residual symptoms of vertigo, nausea, and vomiting. However the use of medications is not routine in the treatment of BPPV.¹

Recurrence of PPV

Definition and Significance of Recurrence 

What constitutes recurrence

Recurrence of BPPV is defined as the reappearance of symptoms after at least one month from an effective repositioning therapy.⁴

Impact on patients’ quality of life

The frequent recurrences of BPPV may cause great inconvenience in the daily life of the patients.⁴ Persistent nausea and vomiting can also become an issue for some patients. 

The sudden head movements while driving or riding a bike may trigger an episode of benign paroxysmal positional vertigo and result in a collision.¹

Risk Factors for Recurrence

Age and gender

Studies have shown that advanced age, female gender, and history of trauma are not significant factors in the recurrence of BPPV unless the patient has other comorbidities.⁴

Comorbid conditions

There are a variety of conditions that have been associated with recurrence of BPPV, including migraine, diabetes, osteoporosis and vascular disorders (hypertension). In addition, low vitamin D levels, and high anti-thyroid autoantibody levels in the plasma can also be associated with higher recurrence rate of BPPV.²

Frequency and Patterns of Recurrence

Many studies have found that most patients (53%) experience recurrence within the first two years. And that half of the recurrent episodes occurs within the first 6 months after the first attack.⁴

Relapse in PPV

What is Relapse?

Relapse is defined as the emergence of new symptoms or the worsening of previous symptoms that usually indicate disease progression. This rarely occurs in BPPV. 

Majority of cases respond to repositioning therapy. Less than 1% of BPPV cases ever need surgery.¹

Causes and Contributing Factors

Comorbidities including hypertension, diabetes, thyroid disorders, hyperlipidemia, and osteoporosis may be responsible for the increased frequency of recurrence of BPPV following treatment. If such a correlation exists in the patient, appropriate treatment of these conditions may be useful in reducing the frequency of recurrence.⁴

Summary 

BPPV is a common cause of recurrent vertigo, especially in elderly women, that is usually not associated with an underlying cause. The attacks in BPPV are short-lived, lasting only seconds. The condition is not associated with hearing loss. The underlying mechanism of BPPV is the displacement of some particles in the canals of the inner ear. BPPV can be diagnosed by performing a simple maneuver called Dix-Hallpike manoeuvre. The treatment of BPPV is by performing a repositioning manoeuvre without the need of medications. However, the recurrence of the condition is frequent, even after effective repositioning therapy, requiring repetitive repositioning manoeuvre.