Benign Paroxysmal Positional Vertigo

One of the most common and most treatable causes of vertigo.  It is defined as an abnormal sensation of movement elicited by certain positions.

Pathophysiology

Within the inner ear are collections of calcium crystals (otoconia/otoliths) that move in the endolymph with movement of the head to stimulate hair cells within the utricle.  In BPPV, these otoliths are displaced into on of the semi-circular canals (most commonly the posterior canal) and so cause a sensation of spinning when the head is positioned in certain ways.

Signs/Symptoms

Vertigo is the primary symptoms.  It must have a rotational component and is not present all the time (episodes lasting a 30 secs to a few minutes).  The vertigo is positional in onset- i.e. it will come on with particular head movements, e.g. turning in bed.  The vertigo is severe and will often cause nausea (although actual vomiting is rarer).

There will be nystagmus during the attack, where the top pole of the eyes rotate towards the affected ear.  This will cause visual spinning for the patient.

Diagnosis

The Hallpike manoeuvre

see also http://www.youtube.com/watch?v=vRpwf2mI3SU

1. Patient is sitting upright on bed with legs extended.
2. The investigator rotates their head 45° and then lowers the patient to lie down quickly with their head in roughly 20° extension below the bed.
3. Observe the eyes for nystagmus (indicates BPPV).

Treatment

The Epley manoeuvre

1. The patient begins in an upright sitting posture, with the legs fully extended and the head turned 45 degrees towards the affected side.
2. The patient then quickly lies down backwards with the head held approximately in a 30 degree neck extension (Dix-Hallpike position) where the affected ear faces the ground.
3. Remain in this position for approximately 30 seconds.
4. The head is then turned 90 degrees to the opposite direction so that the unaffected ear faces the ground, all while maintaining the 30 degree neck extension.
5. Remain in this position for approximately 30 seconds.
6. Keeping the head and neck in a fixed position, the individual rolls onto their shoulder, in the direction that they are facing.
7. Remain in this position for approximately 30 seconds.
8. Finally, the individual is slowly brought up to an upright sitting posture, while maintaining the 45 degree rotation of the head.
9. Hold sitting position for up to 30 seconds.

The entire procedure should be repeated two more times, for a total of three times

This works by repositioning the otoliths in the inner ear- the patient should be asked to try and sleep sitting up for several nights and to not make any rapid head movements to dislodge the crystals.  The duration of effect is variable for different patients, but most will appreciate the acute resolution of symptoms.

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