Benign Paroxysmal Positional Vertigo

BENIGN PAROXYSMAL POSITIONAL
VERTIGO
In Benign Paroxysmal Positional Vertigo (BPPV) dizziness
is thought to be due to debris which has collected within a
part of the inner ear. This debris can be thought of as "ear
rocks", although the formal name is "otoconia". Ear rocks
are small crystals of calcium carbonate derived from a
structure in the ear called the "utricle" (figure1 ). While the
saccule also contains otoconia, they are not able to migrate
into the canal system. The utricle may have been damaged
by head injury, infection, or other disorder of the inner ear,
or may have degenerated because of advanced age.
Normally otoconia appear to have a slow turnover. They
are probably dissolved naturally as well as actively
reabsorbed by the "dark cells" of the labyrinth (Lim, 1973,
1984), which are found adjacent to the utricle and the
crista, although this idea is not accepted by all (see Zucca,
1998, and Buckingham, 1999).
BPPV is a common cause of dizziness. About 20% of all

dizziness is due to BPPV. The older you are, the more likely it is that your dizziness is due to BPPV, as about
50% of all dizziness in older people is due to BPPV. In a recent study, 9% of a group of urban dwelling elders
were found to have undiagnosed BPPV (Oghalai, J. S., et al., 2000).
The symptoms of BPPV include dizziness or vertigo, lightheadedness, imbalance, and nausea. Activities
which bring on symptoms will vary among persons, but symptoms are almost always precipitated by a change
of position of the head with respect to gravity. Getting out of bed or rolling over in bed are common
"problem" motions . Because people with BPPV often feel dizzy and unsteady when they tip their heads back
to look up, sometimes BPPV is called "top shelf vertigo." Women with BPPV may find that the use of
shampoo bowls in beauty parlors brings on symptoms. An intermittent pattern is common. BPPV may be
present for a few weeks, then stop, then come back again.
WHAT CAUSES BPPV?

The most common cause of BPPV in people under age 50 is head injury . There is also an association with
migraine (Ishiyama et al, 2000). 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 (Froeling et al, 1991). 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 vestibular neuritis , minor strokes such as those involving anterior inferior cerebellar
artery (AICA) syndrome", and Meniere's disease are significant but unusual causes. Occasionally BPPV
follows surgery, where the cause is felt to be a combination of a prolonged period of supine positioning, or ear
trauma when the surgery is to the inner ear (Atacan et al 2001). Other causes of positional symptoms are
discussed here.
HOW IS THE DIAGNOSIS OF BPPV MADE?

Your physician can make the diagnosis based on your history, findings on physical examination, and the
results of vestibular and auditory tests. Often, the diagnosis can be made with history and physical
examination. Most other conditions that have positional dizziness get worse on standing rather than lying
down (e.g. orthostatic hypotension). Electronystagmography (ENG) testing may be needed to look for the
characteristic nystagmus (jumping of the eyes). It has been claimed that BPPV accompanied by unilateral
lateral canal paralysis is suggestive of a vascular etiology (Kim et al, 1999). For diagnosis of BPPV with
laboratory tests, it is important to have the ENG test done by a laboratory that can measure vertical eye
movements. A magnetic resonance imaging (MRI) scan will be performed if a stroke or brain tumor is
suspected. A rotatory chair test may be used for difficult diagnostic problems. It is possible but very
uncommon to have BPPV in both ears (bilateral BPPV).
There are some rare conditions that have symptoms that resemble BPPV. Patients with certain types of central
vertigo such as the spinocerebellar ataxias may have "bed spins" and prefer to sleep propped up in bed (Jen et
al, 1998). These conditions can generally be detected on a careful neurological examination and also are
generally accompanied by a family history of other persons with similar symptoms.
HOW MIGHT BPPV AFFECT MY LIFE?

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.
HOW IS BPPV TREATED?

 Office Treatment
 Home Treatment
 Surgical Treatment
BPPV has often been described as "self-limiting" because symptoms often subside or disappear within six
months of onset. Symptoms tend to wax and wane. Motion sickness medications are sometimes helpful in
controlling the nausea associated with BPPV but are otherwise rarely beneficial. However, various kinds of
physical maneuvers and exercises have proved effective. Three varieties of conservative treatment, which
involve exercises, and a treatment that involves surgery are described in the next sections.
OFFICE TREATMENT OF BPPV: The Epley and Semont

Maneuvers
There are two treatments of BPPV that are usually performed in the
doctor's office. Both treatments are very effective, with roughly an
80% cure rate, according to a study by Herdman and others (1993).
If your doctor is unfamiliar with these treatments, you can find a list
of knowledgeable doctors from the Vestibular Disorders
Association (VEDA) .
The maneuvers, named after their inventors, are both intended to

move debris or "ear rocks" out of the sensitive part of the ear
(posterior canal) to a less sensitive location. Each maneuver takes
about 15 minutes to complete. The Semont maneuver (also called
the "liberatory" maneuver) involves a procedure whereby the patient
is rapidly moved from lying on one side to lying on the other. It is a
brisk maneuver that is not currently favored in the United States.
The Epley maneuver is also called the particle repositioning, canalith repositioning procedure, and modified
liberatory maneuver. It is illustrated in figure 2. Click here for an animation. It involves sequential movement
of the head into four positions, staying in each position for roughly 30 seconds. The recurrence rate for BPPV
after these maneuvers is about 30 percent at one year, and in some instances a second treatment may be
necessary. While some authors advocate use of vibration in the Epley maneuver, we have not found this useful
in a study of our patients (Hain et al, 2000).
After either of these maneuvers, you should be prepared to follow the instructions below, which are aimed at
reducing the chance that debris might fall back into the sensitive back part of the ear.
INSTRUCTIONS FOR PATIENTS AFTER OFFICE TREATMENTS (Epley or Semont maneuvers)
1. Wait for 10 minutes after the maneuver is performed before going home. This is to avoid "quick spins," or
brief bursts of vertigo as debris repositions itself immediately
after the maneuver. Don't drive yourself home.
2. Sleep semi-recumbent for the next two nights. This means

sleep with your head halfway between being flat and upright (a
45 degree angle). This is most easily done by using a recliner
chair or by using pillows arranged on a couch (see figure 3).
During the day, try to keep your head vertical. You must not go
to the hairdresser or dentist. No exercise which requires head
movement. When men shave under their chins, they should bend
their bodies forward in order to keep their head vertical. If
eyedrops are required, try to put them in without tilting the head back. Shampoo only under the shower.
3. For at least one week, avoid provoking head positions that might bring BPPV on again.
 Use two pillows when you sleep.

 Avoid sleeping on the "bad" side.
 Don't turn your head far up or far down.
Be careful to avoid head-extended position, in which you are lying on your back, especially with your head
turned towards the affected side. This means be cautious at the beauty parlor, dentist's office, and while
undergoing minor surgery. Try to stay as upright as possible. Exercises for low-back pain should be stopped
for a week. No "sit-ups" should be done for at least one week and no "crawl" swimming. (Breast stroke is
OK.) Also avoid far head-forward positions such as might occur in certain exercises (i.e. touching the toes).
Do not start doing the Brandt-Daroff exercises immediately or 2 days after the Epley or Semont maneuver,
unless specifically instructed otherwise by your health care provider.
4. At one week after treatment, put yourself in the position that usually makes you dizzy. Position yourself
cautiously and under conditions in which you can't fall or hurt yourself. Let your doctor know how you did.
Comment: Massoud and Ireland (1996) stated that post-treatment instructions were not necessary. While we
respect these authors, at this writing (2002), we still feel it best to follow the procedure recommended by
Epley.
WHAT IF THE MANEUVERS DON'T WORK?
These maneuvers are effective in about 80% of patients with BPPV (Herdman et al, 1993). If you are among
the other 20 percent, your doctor may wish you to proceed with the Brandt-Daroff exercises, as described
below. If a maneuver works but symptoms recur or the response is only partial (about 40% of the time
according to Smouha, 1997), another trial of the maneuver might be advised. The "habituation" exercises are
also sometimes useful in the situation where all other maneuvers (Epley, Semont, Brandt-Daroff) have been
tried -- in essence these consist of a more intense and prolonged series of positional exercises. When all
maneuvers have been tried, the diagnosis is clear, and symptoms are still intolerable, surgical management
(posterior canal plugging) may be offered.
BPPV often recurs. About 1/3 of patients have a recurrence in the first year after treatment, and by five years,
about half of all patients have a recurrence (Hain et al, 2000; Nunez et al; 2000). If BPPV recurs, in our
practice we usually retreat with one of the maneuvers above, and then follow this with a once/day set of the
Brandt-Daroff exercises.
In some persons, the positional vertigo can be eliminated but imbalance persists. In these persons it may be
reasonable to undertake a course of generic vestibular rehabilitation, as they may still need to compensate for
a changed utricular mass or a component of persistent vertigo caused by cupulolithiasis. Fujino et al (1994)
reported conventional rehab has some efficacy, even without specific maneuvers.
HOME TREATMENT
OF BPPV:
BRANDT-DAROFF EXERCISES
Click here for an animation
The Brandt-Daroff Exercises are a method of treating

BPPV, usually used when the office treatment fails.
They succeed in 95% of cases but are more arduous
than the office treatments. These exercises are
performed in three sets per day for two weeks. In each
set, one performs the maneuver as shown five times.
1 repetition = maneuver done to each side in turn (takes

2 minutes)
Suggested Schedule for Brandt-

Daroff exercises
Time Exercise Duration
5 10
Morning
repetitions minutes
5 10
Noon
repetitions minutes
5 10
Evening
repetitions minutes
Start sitting upright (position 1). Then move into the side-lying position (position 2), with the head angled
upward about halfway. An easy way to remember this is to imagine someone standing about 6 feet in front of
you, and just keep looking at their head at all times. Stay in the side-lying position for 30 seconds, or until the
dizziness subsides if this is longer, then go back to the sitting position (position 3). Stay there for 30 seconds,
and then go to the opposite side (position 4) and follow the same routine..
These exercises should be performed for two weeks, three times per day, or for three weeks, twice per day.
This adds up to 52 sets in total. In most persons, complete relief from symptoms is obtained after 30 sets, or
about 10 days. In approximately 30 percent of patients, BPPV will recur within one year. If BPPV recurs, you
may wish to add one 10-minute exercise to your daily routine (Amin et al, 1999). The Brandt-Daroff exercises
as well as the Semont and Epley maneuvers are compared in an article by Brandt (1994), listed in the
reference section.

Benign Paroxysmal Positional Vertigo

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BENIGN PAROXYSMAL POSITIONAL

BPPV is a common cause of dizziness. About 20% of all

WHAT CAUSES BPPV?

HOW IS THE DIAGNOSIS OF BPPV MADE?

HOW MIGHT BPPV AFFECT MY LIFE?

HOW IS BPPV TREATED?

OFFICE TREATMENT OF BPPV: The Epley and Semont

The maneuvers, named after their inventors, are both intended to

INSTRUCTIONS FOR PATIENTS AFTER OFFICE TREATMENTS (Epley or Semont maneuvers)

2. Sleep semi-recumbent for the next two nights. This means

 Use two pillows when you sleep.

Click here for an animation

The Brandt-Daroff Exercises are a method of treating

1 repetition = maneuver done to each side in turn (takes

Suggested Schedule for Brandt-

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