Benign Paroxysmal Positional Vertigo (BPPV)

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What is BPPV? (Benign Paroxysmal Positional Vertigo)

BPPV is a disease of the balance organ in the inner ear (vestibule) which results from the altered function of the utricle and posterior semi  circular canal.. Small crystals of calcium carbonate (“otoconia”) normally present in the utricle, drop into the posterior semi  circular canal during head movement. The crystals can lodge in the posterior semi circular canal (Commonest) (Canalithiasis) or in the Cupula of the posterior canal (Cupulolithiasis) The vertigo occurs in sudden brief episodes and is short lived (paroxysmal); it is positional because the symptoms are precipitated by head movement. Some people feel it when the head is taken back to look up, while others feel it if they lie down suddenly or get up suddenly.

BPPV is a common cause of dizziness. About 20% of all dizziness is due to BPPV. In the elderly,  about 50% of  dizziness is due to BPPV

What causes it?

BPPV can be due to simple infections like common colds, and degeneration of the inner ear as in ageing. However, BPPV may rarely occur for no known reason.

The most common cause of BPPV in people under age 50 is head injury with damage to the utricle. There is also an association with migraine. In older people, the most common cause is degeneration of the vestibular system of the inner ear. BPPV becomes much more common with advancing age. In half of all cases, BPPV is called “idiopathic,” which means it occurs for no known reason. Viruses affecting the ear such as those causing vastibular neuritis, minor strokes such as those involving anterior inferior cerebellar artery (AICA Syndrome, and Meniere’s disease are unusual causes. Occasionally BPPV follows surgery. The cause b in such cases could be a combination of a prolonged period of supine positioning, or ear trauma when the surgery is to the inner ear.

How is the diagnosis confirmed?

Positional testing by the Hallpike maneuvers help identify the specific positions provoking the vertigo.

Pure tone Audiometry, Impedance bridge studies and vestibular (balance) tests – Electronystagmography is the gold standard by which the function of the balance organ is measured.  A C.T.Scan or M.R.I.Scan of the brain is not required immediately and usually turns out to be normal. Low blood pressure can give rise to positional vertigo. However in these cases the giddiness is only on sitting up (postural hypotension) and never on lying down.

How is an acute attack managed?

During an acute attack, lie down on a firm surface. Stay as motionless as possible and keep your eyes open and fixed on a stationery object in front of you. Do not try to sip or drink water as this may cause vomiting. Stay like this till the severity of vertigo subsides. Avoid the position causing the vertigo.

How is it treated?

The specific positions provoking the vertigo are identified by the vertigo specialist and avoided and a combination of medication and vestibular rehabilation therapy and course of exercises is advised. Also special exercises help to come back to normal early. The Eppley-Semont manoeuvres are effective in helping the symptoms subside.

Certain modifications in your daily activities may be necessary to cope with your dizziness. Use two or more pillows at night. Avoid sleeping on the “bad” side. In the morning, get up slowly and sit on the edge of the bed for a minute. Avoid bending down to pick up things, and extending the head, such as to get something out of a cabinet. Be careful when at the dentist’s office, the beauty parlor when lying back having ones hair washed, when participating in sports activities and when you are lying flat on your back.

The specific positions provoking the vertigo are identified by the E.N.T Surgeon and avoided and a combination of medication and vestibular therapy is advised. Labyrinthine sedatives, vasodilators. Also special exercises help to come back to normal early. The Eppley-Semont manoeuvre performed by an E.N.T Surgeon are effective in helping the symptoms subside.

Balance is maintained by 3 sources of input to the brain – Inner, ear, the main balance organ, eyes – vision to information received from your feet, ankle and legs assist you in keeping your balance and moving around.

Modifications in the daily activities will help you cope with your dizziness.

The exercises aim at helping one Dependance on vision.- on the information received from the eyes.

Because of this you should take special precautions in situations where clear, normal vision is not available to you to avoid injury in case you fall. At home, when walking through dark rooms, keep lights or night lights on all the time. Eliminate slippery floor surfaces, maintain clear a path to your bathroom and move away objects that could injure you, should you have a fall. Do not drive your car at night, during stormy weather or when visibility is poor. Do not carry large objects which obstruct the view in front.

Dependance on inputs from awareness of contact with the floor through the skin, joint position awareness, muscle tone awareness

Take great care when walking on soft rugs, carpeted floors, sand or loose gravel and other uneven surfaces. Make sure, the floors at home are free from obstructions. Maintain a clear path to your bathroom and move away all objects along the floor that could entangle your feet or injure you, should you have a fall. Most important, do not place yourself in a situation where you might lose your balance and be at risk of falling and serious injury; stay off chairs, stools, ladders, roofs. Exercise special care in the kitchen, near an open flame. Take extra care crossing roads, avoid sitting on two wheelers and avoid heights.