What is Benign Paroxysmal Positional Vertigo?

The most prevalent peripheral vestibular end-organ illness, benign paroxysmal positional vertigo (BPPV) is characterized by a rapid, brief gyratory sensation accompanied by distinctive nystagmus. Vertigo of this sort is by far the most prevalent.

BPPV has a lifetime frequency of 2.4 percent and a reported prevalence of 10.7 to 64.0 instances per 100,000 people. Symptoms are triggered by changes in the position of the head concerning gravity.  They can range in severity from minor dizziness to debilitating episodes that can cause nausea, vomiting, and significantly obstruct normal functioning.

Causes and Symptoms

BPPV can be caused by a variety of medical problems. Comorbidities are frequent among the elderly, and they can have a significant impact on their quality of life. Tinnitus, hearing loss, and vestibular hypofunction are the prevalent neurotological problems associated with dizziness and balance issues in the elderly.

Common pathologies in senior age, such as hypertension and diabetes mellitus, have been linked to gradual hearing loss or even sudden sensorineural hearing loss, and there has also been a link discovered between psychiatric problems and vestibular diseases. BPPV can be separated from idiopathic and secondary BPPV, which are caused by otoconia separation for a variety of reasons.

The symptomatology of BPPV is caused by abnormal semicircular canal signaling, which gives the impression of motion. The canalithiasis and cupulolithiasis models are the two most popular explanations for BPPV pathogenesis, and they differ in how endolymphatic debris affects cupular dynamics. The most common subtype, according to a clinicopathological study, is canalithiasis. Many believe that misplaced otolithic membrane pieces are to blame for the development of disease-causing canaliths.

The majority of BPPV instances are idiopathic in nature and are caused by macula degeneration. Secondary causes of BPPV are causes of otoconial dislodgement that can be identified. Otologic and nonotologic surgery, head trauma, or any other means of delivering sufficient mechanical stress to the inner ear are some examples.

Prevalence

Idiopathic BPPV is more common in the elderly and among women, peaking between 50 and 60 years of age and with a female-to-male ratio of 2:1 to 3:1. The high prevalence of BPPV results in a disproportionately large healthcare burden in the United States, amounting to almost $2 billion each year. BPPV is the most common cause of vertigo, with 17% to 42% of patients with vertiginous symptoms being diagnosed with the virus. The lifetime prevalence of BPPV was estimated to be 2.4 % in one European cross-sectional survey, while the incidence was found to be 10.7 to 64 instances per 100,000 per year in the following studies.

BPPV can appear at any age, however, it is more common in the fifth and sixth decades of life.

Diagnosis and Treatment

In patients with vertigo, the diagnosis process begins with a thorough review of their medical history. Following a careful record of their symptoms and duration, previous surgical operations, a general physical and neurological examination, history of infections or trauma, and medications should be undertaken. In the context of a full otolaryngologic examination, otoscopy should be performed to rule out evident abnormalities in the external or middle ear, as well as confounding symptoms. To diagnose BPPV, a thorough history must be taken. Many episodes of idiopathic BPPV are likely connected to sleeping, and patients frequently report experiencing vertigo while lying in bed, rolling from side to side, or rising from bed in the morning.

The Dix-Hallpike technique is used to confirm BPPV diagnosis. The test is carried out by swiftly lowering the patient from a sitting posture to a position where the patient's head hangs 20°–40° below horizontal over the side of the bed, with the test ear undermost. The examiner should test the ear with the least suspicion first, but in circumstances when there is no indication of laterality, it doesn't matter. When a patient complains of vertigo with associated nystagmus, the response is considered favorable.

The Dix-Hallpike maneuver is the standard and most effective test for diagnosing BPPV of posterior SCC, but there are several contraindications and protective measures that should be taken on occasion.  In patients with vascular disease, the risk of vascular damage and stroke should constantly be recognized. Patients with morbid obesity, lower back pain and dysfunction, advanced rheumatoid arthritis, cervical radiculopathy, cervical spinal stenosis, limited cervical motion, and kyphoscoliosis which are more common in older people, should be treated with caution. The Dix-Hallpike test can be safely performed in patients who have physical limitations thanks to specially designed adjustable examination tables.

BPPV usually goes away on its own without any treatment. In untreated patients, the median interval between the beginning of symptoms and spontaneous remission was 7 days when the horizontal canal was afflicted and 17 days when the posterior canal was damaged, according to a prospective longitudinal study.

Canalith-repositioning techniques, on the other hand, can be employed to cure BPPV quickly and successfully. The majority of medications are used to treat severe nausea and vomiting. Transsection of the posterior ampullary (singular) nerve and plugging of the affected canal is rarely necessary and should only be considered in patients with intractable and incapacitating symptoms who have not responded to repositioning maneuvers.

References:

• Zhu, C. T., Zhao, X. Q., Ju, Y., Wang, Y., Chen, M. M., & Cui, Y. (2019). Clinical Characteristics and Risk Factors for the Recurrence of Benign Paroxysmal Positional Vertigo. Frontiers in neurology, 10, 1190. https://doi.org/10.3389/fneur.2019.01190
• Balatsouras, D. G., Koukoutsis, G., Fassolis, A., Moukos, A., & Apris, A. (2018). Benign paroxysmal positional vertigo in the elderly: current insights. Clinical interventions in aging, 13, 2251–2266. https://doi.org/10.2147/CIA.S144134
• You, P., Instrum, R., & Parnes, L. (2019). Benign paroxysmal positional vertigo. Laryngoscope investigative otolaryngology, 4(1), 116-123. https://doi.org/10.1002/lio2.230
• Kim, J. S., & Zee, D. S. (2014). Clinical practice. Benign paroxysmal positional vertigo. The New England journal of medicine, 370(12), 1138–1147. https://doi.org/10.1056/NEJMcp1309481

Further Reading

• All Vertigo Content
• What is vertigo?
• Vertigo Causes
• Vertigo Symptoms
• Vertigo Diagnosis

Written by

Aimee Molineux

Aimee graduated from Oxford University with an undergraduate degree in Japanese and Korean Studies, with an exchange year at Kobe University in Hyogo, Japan. Throughout her studies, Aimee took part in various internships, gaining an interest in marketing and editorial work along the way.In her personal time, Aimee can be found either attempting to cook, learning how to code, doing pilates, as well as regularly updating her pet hamster’s Instagram account.