Benign Paroxysmal Positional Vertigo

By far the largest number of patients with true vertigo suffer from benign paroxysmal positional vertigo (BPPV). It was first described many years ago by Dix and Hallpike, but Dr. John Epley has re-investigated it more recently. He has developed a reliable curative procedure that can be done in the office. It has been found, with proven anatomic evidence, that the vertigo of these patients is due to otolithic debris (now termed canaliths) in the long limb of the posterior semicircular canal. These are displaced otoliths that are normally present over the stereocilia of the position-sensing hair cells in the utricle. Head trauma, or other less clear causes, put them in the wrong place. They create a physical "drag" on fluid motion in this semicircular canal, and the result is the classic symptom-complex seen in this disorder.

A typical patient complains of vertigo lasting a few seconds to a halfminute when the head position changes with respect to gravity. This usually occurs when lying down, arising from bed, looking upward, or bending forward. When supine, it is experienced when the individual rolls over to one specific side. A history of head trauma may exist, but not necessarily. The symptoms are often relentless, and over a period of time the patient learns to avoid the positions most likely to cause the vertigo, or else moves with great care in certain directions. There is no associated hearing deficit.

The Hallpike maneuver, a rapid shift from sitting to supine with the head hyperextended and turned 45° to the affected side, will produce vertigo and rotary nystagmus. Usually the nystagmus comes on after a lag period of a few seconds, and then abates after 30 seconds or less. This diagnostic maneuver can be done in the office. ENG, if using this maneuver during positional testing, will document the finding. The disease is usually unilateral, and the ear that is downward when the nystagmus occurs is the culprit.

Prior to the procedure developed by Epley, treatment consisted of reassurance and meclizine or the like, which did very little for this specific disorder. The clinical course remained chronic and recurrent. Now, there is the canalith repositioning procedure, a fairly simple manipulation designed to get the debris out of the posterior canal. This is often effective after the first try, and the success rate improves with repetition. Figure 8.3 demonstrates the Epley procedure.

Benign Paroxysmal Positional Vertigo

Fig. 8.3 The Epley canalith repositioning procedure.

Positioning sequence for left posterior semicircular canal, as viewed by operator (behind patient). Box, Exposed view of labyrinth, showing migration of particles (large arrow). S, Start-patient seated (oscillator applied). 7, Place head over end of table, 45 degrees to left. 2, Keeping head tilted downward, rotate to 45 degrees right. 3, Rotate head and body until facing downward 135 degrees from supine. 4. Keepng head turned right, bring patient to sitting position. 5, Turn head forward, chin down 20 degrees. Pause at each position until induced nystagmus approaches termination, or for T (latency + duration) seconds if no nystagmus. Keep repeating entire series (7-5) until no nystagmus in any position.

(Source: Epley JM, Particle Repositioning for Benign Paroxysmal Positional Vertigo. The Otolaryngologic Clinics of North America. 1996;29:2:327.)

Fig. 8.3 The Epley canalith repositioning procedure.

Positioning sequence for left posterior semicircular canal, as viewed by operator (behind patient). Box, Exposed view of labyrinth, showing migration of particles (large arrow). S, Start-patient seated (oscillator applied). 7, Place head over end of table, 45 degrees to left. 2, Keeping head tilted downward, rotate to 45 degrees right. 3, Rotate head and body until facing downward 135 degrees from supine. 4. Keepng head turned right, bring patient to sitting position. 5, Turn head forward, chin down 20 degrees. Pause at each position until induced nystagmus approaches termination, or for T (latency + duration) seconds if no nystagmus. Keep repeating entire series (7-5) until no nystagmus in any position.

(Source: Epley JM, Particle Repositioning for Benign Paroxysmal Positional Vertigo. The Otolaryngologic Clinics of North America. 1996;29:2:327.)

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Summary

Benign paroxysmal positional vertigo is the most common syndrome of vertigo. It is characteristically recognized by the symptom of true vertigo when lying down with the head turned to one side. Other position changes may also precipitate it. There are no other ear or hearing symptoms. A unilateral vestibular abnormality has been demonstrated, and Epley's well-described maneuver is often curative. The primary practitioner can diagnose it in the office by using the Hallpike maneuver, or by referral for ENG testing to document the nystagmus. The Epley maneuver can then be performed. If the clinician has any doubts, ENT consultation can be obtained.

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