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Thursday, 21 January 2021 2.19 AM IST

Tackling benign paroxysmal positional vertigo

vertigo

A 53-year-old computer professional has problem of recurrent vertigo. It comes suddenly and really makes her helpless. Many at times there is a tendency to fall with a nauseating sensation. Vertigo is maximum in the morning. Many medications tried but no permanent relief. Have seen so many doctors and have done many tests. But all seem normal. Tried many exercises as per doctors’ advice but has not produce any satisfactory relief.

What can be the permanent solution for this disgusting problem? Benign paroxysmal positional vertigo (BPPV) is the most common disorder of the inner ear’s vestibular system, which is a vital part of maintaining balance. Usually benign and generally not progressive. BPPV produces a sensation of spinning called vertigo that is both paroxysmal and positional, meaning it occurs suddenly and with a change in head position. It’s typically unilateral, although in some cases it is bilateral.

BPPV occurs as a result of otoconia, tiny crystals of calcium carbonate that are a normal part of the inner ear’s anatomy, detaching from the otolithic membrane in the utricle and collecting in one of the semi-circular canals. When the head is still, gravity causes the otoconia to clump and settle. When the head moves, the otoconia shift. This stimulates the cupula to send false signals to the brain, producing vertigo and triggering nystagmus (involuntary eye movements).

Symptoms Mainly vertigo, then dizziness (light-headedness), imbalance, difficulty concentrating, and nausea. Symptoms are precipitated by changing the head’s position with respect to gravity. With the involvement of the posterior semi-circular canal in classic BPPV, common problematic head movements include looking up, or rolling over and getting out of bed.

BPPV may be experienced for a very short duration or it may last a lifetime, with symptoms occurring in an intermittent pattern that varies by duration, frequency, and intensity. It can be tremendously disruptive to a person’s work and social life, as well as pose a health hazard due to an increased risk of falls associated with dizziness and imbalance.

Etiology

The most common cause of BPPV in people under age 50 is head injury and is presumably a result of concussive force that displaces the otoconia. In people over age 50, BPPV is most commonly idiopathic, (occurs for no known reason), but is generally associated with natural age-related degeneration of the otolithic membrane. BPPV is also associated with migraine, cervical spondylitis and ototoxicity. Viruses affecting the ear (such as those causing vestibular neuritis) and Meniere’s disease are unusual causes. Occasionally BPPV follows surgery or after long periods of inactivity.

Diagnosis

BPPV is diagnosed based on medical history, physical examination, the results of vestibular and auditory (hearing) tests, and possibly lab work to rule out other diagnoses. Vestibular tests include the Dix-Hallpike maneuver and the Supine Roll test.. A radiographic imaging such as a magnetic resonance imaging scan (MRI) to rule out other problems such as a stroke or brain tumor, Auditory tests to help pinpoint a specific cause of BPPV, such as Meniere’s disease or labyrinthitis.

Treatment
Recommended treatment for most forms of BPPV employs particle repositioning head maneuvers (Epley manoeuvre) that move the displaced otoconia out of the affected semi-circular canal and back into their proper location in the utricle. These maneuvers involve a specific series of patterned head and trunk movements that can be performed in a health care provider’s office in about 15 minutes. A single particle repositioning procedure is effective in treating about 80% to 90% of cases of BPPV. Additional exercise or repositioning maneuvers may be needed if symptoms continue.

The particle repositioning procedure (Epley manoevre) begins by sitting up on a bed or table. Turn your head 45 degrees toward the affected ear (see how to determine your affected ear above). Quickly lie back, keeping your head turned toward the affected ear as you lie back with your head slightly over the edge of the bed or table. Wait about a minute or until you stop having symptoms. Without raising your head, turn your head quickly in the opposite direction so that your “good” ear is parallel with but slightly over the edge of the table or bed. Wait about a minute or until you stop having symptoms. Roll onto your side. Continue to turn your head another 45 degrees in the same direction as previous step so that your nose is now facing the floor. Wait about a minute. Keeping your chin tucked in toward your shoulder, sit up in the direction your body is facing.

Post-treatment considerations After successful treatment with particle repositioning maneuvers, residual dizziness is often experienced for up to three months. Patients sleep in an elevated position with two or more pillows and/or not on the side of the treated ear, wear a cervical collar as a reminder to avoid quick head turns, and avoid exercises that involve looking up or down or head rotation.

Other Bppv treatment Options

If head maneuvers don’t work, other treatment options include home-based exercise therapy, surgery, medication, or simply coping with the symptoms while waiting for them to resolve.

Vestibular Rehabilitation Home Exercises After receiving training from a doctor or physical therapist, a patient can perform the exercises at home Brandt-Daroff exercises involve repeating vertigo-inducing movements two to three times per day for up to three weeks, it reduces vertiginous responses to head movements in 95% of cases

Another home exercise method is daily self-administration of particle repositioning head maneuvers.

Surgery If head maneuvers and vestibular rehabilitation exercises are ineffective in controlling symptoms, surgery is sometimes considered..

Several surgical approaches are possible; however, a procedure called posterior canal plugging, also called fenestration and occlusion of the posterior canal, is preferable to other methods. These include removing the balance organs with a labyrinthectomy; severing the vestibular portion of the vestibulo-cochlear nerve with a vestibular nerve section, thus terminating all vestibular signals from the affected side; or severing the nerve that transmits signals from an individual canal with a singular neurectomy.

Medication

Medications are not beneficial always. Motion sickness medications are sometimes helpful in controlling the nausea associated with BPPV and are sometimes used to help with acute dizziness during particle repositioning maneuvers.. Medication that suppresses vestibular function in the long term can interfere with a person making necessary adaptations to symptoms or remaining physically active because of side-effects such as drowsiness.

Wait-And-See

Sometimes, adopting a “wait-and-see” approach is used for BPPV because it frequently resolves without intervention.

Coping strategies during this wait-and-see phase can involve modifying daily activities to help minimize symptoms. This may involve using two or more pillows while in bed, avoiding sleeping on the affected side, and rising slowly from bed in the morning. Other modifications include avoiding looking up, such as at a high cupboard shelf, or bending over to pick up something from the floor. Patients with BPPV are also cautioned to be careful when positioned in a dentist’s or hairdresser’s chair, when lying supine, or when participating in sports activities.

Dr Arun Oommen

MBBS, MS, Mch ( Neurosurgery), MRCS Ed, MBA

Senior Consultant Neurosurgeon

VPS Lakeshore Hospital

Kochi

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TAGS: TACKLING, BENIGN, PAROXYSMAL, POSITIONAL VERTIGO
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