Lake Atitlan, Guatemala
Health 

Benign Paroxysmal Positional Vertigo

I was recently stuck with BPPV (Benign Paroxysmal Positional Vertigo) which is a horrible condition. After some struggle at hospitals and clinics, I've put together some info that will hopefully be helpful to other sufferers.


My story

I woke up one morning and couldn't lift my head off of the pillow, or the room started spinning really fast. I panicked, but remained in bed, and over the next 20 minutes I managed to slowly move myself into a sitting position.

Over the next few days I had to avoid tilting my head back or the vertigo kicked in. I was also in a constant state of dizziness, as if I was partly asleep.

I researched a bit on the Internet and found a physical maneuver that cured the vertigo, which I continued to do twice a day. However the constant dizziness remained, so I went to a clinic to get some help. They did some blood work which all indicated I was healthy, so they suggested that I continue with the maneuvers, which I did.

However after two weeks of no progress, I stopped with the maneuvers and a few days later the vertigo came back.

I decided to go to a hospital and they suggested a different maneuver which I did, but it did not cure me, rather it made conditions worse. So I felt like reading up on the subject more and find a solution on my own.

Overview

BPPV is a problem in the balance organ of the inner ear. 

  • Benign - not life threatening
  • Paroxysmal - comes in short spells of 15 to 60 seconds
  • Positional - is only triggered when the head moved in certain directions
  • Vertigo - a strong dizziness, as if the room is spinning around

The balance organ is made up by three semicircular ducts, each one in a different plane so they can cover all three dimensions of movement. The ducts are filled with a fluid, and have tiny hairs connected to nerves that pick up fluid movement. 

The above picture shows the right inner ear from the side.

  • The anterior duct (sometimes called the superior duct) detects head tilting to the side, such as lying down on the side.
  • The posterior duct detects when the head is turned up and down, such as when nodding.
  • The lateral duct (sometimes called the horizontal duct) detects head turning, such as when saying no. 

When the head is still, the hairs in the ducts are not affected, and no signal is sent to the brain. When the head is moved, for example in a nodding motion, the posterior duct will be rotated relative to the earth. At the same time the fluid in the duct will stay in place relative to the earth because of inertia. In effect this creates a flow in the duct which is picked up by the tiny hairs, and the brain gets informed that the head is doing a nodding motion. This makes the autonomic nervous system create a movement of the eyes, so they still face the same direction.

The three ducts are connected to a hollow space called the utricle, in which there are tiny calcium crystals called otoconia. Sometimes a crystal gets dislodged from the utricle and is moving around in one of the ducts. BPPV is triggered when the head is put in a certain angle, so that the dislodged crystal is pulled down through a duct by gravity. This makes the crystal push on the fluid, which in turn gives a false sensation of head movement. The result is vertigo with eyes that turn rapidly back and forth. This involuntary eye movement is called nystagmus, and has two parts: a fluid pupil movement to one side, followed by a quick twitch back to the original side, and then continuously repeated. The twitching direction is said to be the direction of the nystagmus.

Most cases of BPPV will cure by themselves within one to two months, without any help from a doctor. But the condition is very unpleasant and lifestyle-limiting, so there are certain maneuvers that can be performed to speed up the recovery.

Causes

BPPV is normally seen after trauma to the head, or severe physical or emotional stress, but the real underlying mechanism is unknown. People suffering from migraine are more commonly affected.

Diagnosis

The first thing to do is to find out which duct is affected, and in what ear. The posterior duct is most commonly affected, with the lateral being second, and anterior being uncommon.

The Dix-Hallpike test

This tests for BPPV in the posterior duct, which is the most common form, so it should be done first.

  • Sit up on a bed and turn the head 45 degrees towards the test ear.
  • Lie down quickly on your back, so that the head hangs 30 degrees off the end of the bed.
  • Have someone observe the eye movements. Wait until the nystagmus subsides plus an additional 30 seconds.
  • Return to the upright position and wait 30 seconds.
  • Repeat the entire maneuver to test the other ear.

A successful indication is nystagmus that is torsional (diagonal and slightly circular) and twitching upwards and towards the tested ear. Testing the other ear should not trigger nystagmus. The test can be performed multiple times, and the nystagmus is typically less intense for each test.

If the twitching is upwards/downwards then it might be a case of anterior duct BPPV. This diagnosis should be considered with caution because downbeating nystagmus is also related to various neurological disorders.

If the twitching is purely left/right then it might indicate lateral duct BPPV. In this case the Pagnini-McClure test should be performed.

The Pagnini-McClure test

This tests for BPPV in the lateral duct.

  • Sit up on a bed.
  • Lie down on your back, face up. Bend the neck slightly forward/upward to make sure the head is exactly horizontal.
  • Quickly turn your head 90 degrees to the right. Have someone observe the eye movements. Wait until the nystagmus subsides plus an additional 30 seconds.
  • Turn your head back face up and wait a few moments.
  • Quickly turn your head 90 degrees to the left. Have someone observe the eye movements. Wait until the nystagmus subsides plus an additional 30 seconds.
  • Sit up straight.

The nystagmus should be purely left/right (horizontal), and occur both when the head is turned left and right. 

Eye twitching towards the ground in both positions indicates geotropic BPPV (i.e. right turn has right twitching and left turn has left twitching). This due to canalithiasis, the most common form of BPPV, where the crystal is moving around in the duct.

Eye twitching away from the ground indicates apogeotropic BPPV (i.e. right turn has left twitching and left turn has right twitching). This is due to cupulolithiasis, which is when the crystal is stuck near the end of the duct.

Nystagmus often starts immediately, and goes on for 15 to 60 seconds. The nystagmus usually does not get less intense after multiple tests, so people with this type of BPPV are more likely to get ill from the test.

To determine what ear is affected, first look at twitching direction. If it is the geotropic type, then look at which head turn provokes the strongest nystagmus; if it is during the right turn, then it is the right ear, and vice versa. If it is the apogeotropic type, then it is the opposite: strongest response at the right head turn indicates the left ear and vice versa.

Complications

Two canals can be affected at the same time, but this is very uncommon. Then it is usually posterior duct BPPV combined with lateral duct BPPV. The nystagmus will still follow the patterns of single duct BPPV, although treatment may have to be undertaken in stages in some cases.

Sometimes the crystal moves out of one duct and into another, during treatment or otherwise. This duct switch changes the appearance of nystagmus from that of the original affected duct to that of the newly affected duct.

Treatment

No medicine is needed for treatment; you perform certain maneuvers to force the dislodged crystal back into the utricle where it belongs.

Most people affected with BPPV will have relapses months or years later, but since the cure is simple and effective, this is an affliction that is very manageable.

The maneuvers need only be done once. Repeating them has not shown any additional benefit. The head does not need to be kept level for any substantial time after the treatment.

The Epley maneuver

This maneuver cures posterior duct BPPV, and is very similar to the Dix-Hallpike test.

  • Sit up on a bed and turn the head 45 degrees towards the affected ear.
  • Lie down quickly on your back, so that the head hangs 30 degrees off the end of the bed.
  • Have someone observe for primary stage nystagmus. Should be twitching diagonally towards the affected ear. Wait until the nystagmus ends, plus an additional 30 seconds.
  • Rotate the head 90 degrees towards the healthy ear while maintaining the head-hanging position. Have someone observe for second stage nystagmus. Wait one minute or if you get nystagmus then wait until it subsides plus 30 seconds. 
  • Roll the head and body another 90 degrees towards the healthy side, so you are lying on your side and the head is facing 180 degrees from the original position. Have someone observe for third stage nystagmus. Wait one minute or if you get nystagmus then wait until it subsides plus 30 seconds. 
  • Sit up sideways and stay in this position for five minutes.

If second and/or third stage nystagmus occurs, the eyes should be twitching in the same direction as they did for first stage nystagmus. This is a sign that the crystal is moving in the right direction. If the eyes twitch in a different direction, then the maneuver has failed. Absence of second or third stage nystagmus is fairly common, and might not indicate a failure.

The Barbeque maneuver

    This maneuver cures lateral duct BPPV, and it is very similar to the Pagnini-McClure test. It is also called the Lempert maneuver.

    • Sit up on a bed.
    • Lie down on your back, face up. Bend the neck slightly forward/upward to make sure the head is exactly horizontal.
    • Quickly turn your head 90 degrees towards the affected ear. Have someone observe the eye movements. Wait until the nystagmus subsides plus an additional 30 seconds.
    • Turn your head back face up and wait 30 seconds.
    • Quickly turn your head 90 degrees towards the healthy ear. Have someone observe the eye movements. Wait until the nystagmus subsides plus an additional 30 seconds.
    • Continue to turn 90 degrees in the same direction so that you are face down on the bed. This might not create nystagmus. Wait for 30 seconds.
    • Sit up straight and stay in this position for five minutes.


    References


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