Benign Paroxysmal Positional Vertigo (BPPV) BPPV is the most common form of positional vertigo and it accounts for nearly half of al people with a peripheral vestibular system dysfunction. The prevalence of BPPV in the general population is thought to be 2.4% but the prevalence increases with age. It is seven times more common in persons over the age of 60 compared to persons from 18 to 39 years of age. In people over the age of 65, the incidence may be as high as 35% to 40%. BPPV is more common in women than men in all age groups. What is the vestibular system? The vestibular system compromises five sensory organs that provide your brain with information about head position and movements. The five organs include three semicircular canals and two otoliths (the saccule and utricle). This system, there is one on each side, is also termed the ‘inner ear’ as it is connected to the cochlea which is part of the hearing mechanism. The vestibular system provides information to your brain about head rotational movements, linear movements as well as static positions of the head relative to gravity. What is BPPV? In the otoliths, there are calcium carbonate crystals or otoconia that occur naturally. These ‘ear rocks’ are fixed to a membrane within the saccule and utricle. If they dislodge, they can migrate into one of the semicircular canals where they don’t belong (see diagram). If this happens, then the problem that is caused is termed BPPV. In BPPV, the dislodged otoconia can move when the individual moves their head into certain positions. This movement of the crystals can trigger a nerve to send off erroneous information to the brain, creating the sensation of vertigo (spinning), abnormal eye movements (nystagmus) and usually nausea. -­‐2-­‐ The head movements that typically provoke the vertigo are looking up, looking down, lying down flat quickly and rolling over while lying down. The vertigo is usually short in duration (less than 60 seconds) and goes away if the person stays in the provoking position. Common movements in everyday life that can provoke the vertigo associated with BPPV involve turning over in bed, looking up into a cupboard as well as tilting your head back in a dentist’s chair or having your hair washed at the salon. What causes BPPV? In the majority of cases (35%) there is no known cause for the BPPV (idiopathic onset). Prior head trauma, which can be minor, is present in approximately 15% of cases. In the remainder of cases, BPPV occurs in relationship with a variety of vestibular dysfunctions such as Meniere’s disease, vestibular neuritis/labyrinthitis (15%) and ear surgeries. There is a higher incidence of BPPV in persons who experience migraine headache. How is BPPV assessed? Typically, two tests will be performed in the clinic to look for the presence of otoconia in one or more of the semicircular canals. These tests are the Dix-­‐Hallpike and Head Roll tests. Sometimes a different test, the Side Lying test will be conducted. How is BPPV treated? Most BPPV involves loose or free floating otoconia in the posterior semicircular canal of the vestibular system. Sometimes the otoconia can be in the horizontal semicircular canal. The basis of all of the treatment techniques is to move or ‘float’ the loose otoconia around the semicircular canal in order to reposition them in the saccule where they belong. The treatment usually takes about 10 minutes. If the otoconia are in the posterior canal ((80% to 90%) of all BPPV, then the Epley maneuver will likely be used. There are other techniques that can be used if necessary. -­‐3-­‐ Left Epley maneuver (home treatment) 1. 2. 3. Start sitting on the bed Lie back quickly with Turn your head slowly and turn your head 45 your shoulders on to the right 90 degrees to the left. Place the pillow and your degrees (without a pillow behind you so head reclined on raising it) and that on lying back it the bed at an angle wait until any vertigo will be under your of about 30 degrees has stopped plus shoulders. down. Wait until all another 1 to 2 of the vertigo has minutes. stopped plus another 1 to 2 minutes. -­‐4-­‐ 4. . Roll your body and head another 90 degrees to the right so that you are lying on your right side, looking down to the floor. Keep your head down while you turn over. Wait until any vertigo has stopped plus about 1 to 2 minutes. 5. Sit up slowly from lying on the right side while looking over your shoulder. Be careful as occasionally this movement can bring on some vertigo. -­‐5-­‐ Right Epley maneuver (home treatment) 1. 2. 3. Start sitting on the bed Lie back quickly with Turn your head and turn your head 45 your shoulders on slowly to the degrees to the right. Place the pillow and your left 90 degrees a pillow behind you so head reclined on the bed (without raising that on lying back, it at an angle of about it) and wait until will be under your 30 degrees down any vertigo has shoulders Wait until all stopped plus the vertigo has about 1 to 2 stopped plus about minutes. 1 to 2 minutes. -­‐6-­‐ 4. Roll your body and head another 90 degrees to the left so that you are lying on your left side, looking down to the floor. Keep your head down while you turn over. Wait until any vertigo has stopped plus about 1 to 2 minutes. 5. Sit up slowly from lying on the left side while looking over your shoulder. Be careful as occasionally this movement can bring on some vertigo. -­‐7-­‐ If the otoconia (crystals) are not loose but stuck to a part of the semicircular canal then another technique may need to be used (Liberatory or Semont maneuver) to reposition the crystals. Sometimes, the otoconia are present in the horizontal semicircular canal. If this is the case, then there are a few different techniques that can be used to reposition them back where they belong. How successful is the treatment? Fortunately, the various treatment techniques for BPPV are usually very successful. Many studies have demonstrated success rates of over 80% with one treatment. Some people require multiple treatments and rarely, the BPPV can be difficult to resolve. Can the BPPV recur? Yes the BPPV does recur in many persons. The recurrence rate has been reported as varying from 18% to 37%. It can recur at any time although during the first year after treatment, the recurrence rate is the highest. Will BPPV spontaneously resolve if not treated? In many cases, BPPV will spontaneously resolve on it’s own. One study indicated that the spontaneous remission rate might vary from 33% to 50%. However, it might take a long time for the spontaneous remission to occur and if it does not go away on it’s own, it might be present for many years.