Feature Article

Benign Paroxysmal Positional Vertigo
(BPPV)

Anatomical Mechanism
  Deep within the inner ear, calcium carbonate crystals, or otoconia, are embedded on top of hair cells within the inner membrane of a structure called the utricle. This top-heavy structure detects head movement or change in position relative to gravity and sends a message to your brain to maintain balance, posture, and appropriate eye movement. Benign Paroxysmal Positional Vertigo occurs when otoconia break free from hair cells in the utricle and travel with gravity into the semicircular canals. This may occur for a number of reasons like viral infection, head trauma, or degenerative changes due to aging, but the reason is oftentimes unknown.

  Inside semicircular canals, these crystals move freely when the head is tilted or rotated relative to gravity. This movement activates cells lining the canals that are sensitive to rotary movement of the head. This sends an inaccurate message to the brain that your head is rotating, when indeed it is not. This causes temporary rapid rotational movements of the eyes, called nystagmus. A sense that the room is spinning, vertigo, is also experienced. Symptoms typically occur with any change in position of the head, for example laying down, rolling over, looking up or bending down. Vertigo symptoms from BPPV typically last less than thirty seconds, but the person may feel slightly unsteady throughout the day. Symptoms may also include imbalance, lightheadedness, or nausea. Severity of symptoms depends on the involved canal, the amount of displaced crystals, and individual sensitivity.

Diagnosis:
  Taking a subjective history of the patient’s symptoms and performing a quick physical examination can usually make a diagnosis of BPPV. The examination involves the Dix-Hallpike Maneuver in which the patient is quickly brought from sitting upright to lying on their back with their head turned to the side 45 degrees. This is performed on both the right and left side to be certain which ear is involved. What the practitioner is looking for with this test is nystagmus and or a report of vertigo from the patient. Further testing may be done to rule out an alternate diagnosis.

Treatment:
  The most common active treatment for BPPV is the Epley maneuver. This technique moves the otoconia through and out of the involved semi-circular canal into an area of the inner ear where they will no longer be burdensome. It is done by taking the patient through a series of specific sustained positions focusing on the head. After this treatment is performed, the patient needs to adhere to a specific set of rules for the following two days to prevent the crystals from travelling back into the semicircular canal. These are known as the 48 Hour precautions and include; 1) Not tilting your head up or down 2) Not laying flat, using at least two pillows, and 3) Not laying on your affected side. This treatment has shown to be highly effective in most cases within one or two sessions. Timothy Hain, MD has compiled 9 studies of 394 patients treated with repositioning techniques and they were found to be 81% effective (dizziness-and-balance.com). There are a number of alternate treatments for persistent BPPV, in which the crystals are adhered to the lining in the semicircular canals or to a structure called the cupula. These treatments may involve more forceful movements into and out of positions designed to loosen the crystals.
  Treatment for a variety of vestibular disorders, including BPPV is available at Homer Physical therapy. Vestibular therapist Haley Hughes, DPT received on the job training at a facility in Bellevue, Washington as well as completed a recent vestibular course at the Rehabilitation Institute of Chicago.
  

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