Vertigo is a complaint that often causes patients to seek a consultation with an otolaryngologist. While vertigo-or dizziness-can be a symptom of an underlying medical, neurological, or otologic disorder, the most common cause is benign paroxysmal positional vertigo (BPPV). BPPV is a condition that is usually easy to diagnose and can often be treated in the physician’s office using noninvasive techniques.
Explore this issue:February 2008
Approximately half of all cases of BPPV are considered primary or idiopathic. Secondary causes of BPPV include head trauma, viral labyrinthitis, Ménière’s disease, migraines, and ear surgery. BPPV can occur in individuals of all ages, but it is more common in people over 50 years of age.
BPPV is diagnosed using the Dix-Hallpike maneuver. The patient is quickly taken from a sitting to a prone position with the head hanging over the end of the examining table and turned approximately 45 degrees to the side being tested. The physician then examines the patient’s eyes for nystagmus.
A patient with torsional nystagmus beginning a few seconds after the Dix-Hallpike maneuver almost certainly has BPPV; however, a negative Dix-Hallpike does not automatically rule it out. Dispersion of the particles from the patient’s normal movements throughout the day can result in a negative Dix-Hallpike examination in a patient suffering from BPPV.
Gerard Gianoli, MD, of The Ear and Balance Institute in Baton Rouge, LA, said, If someone has a very clear history for BPPV, and the Dix-Hallpike test is normal, I’ll bring them back first thing in the morning to repeat the test. If that one is normal, I’ll bring them back at least a third time before ruling out BPPV.
Traditional Treatment Options
BPPV is essentially a self-limiting condition, which will often resolve spontaneously if left untreated. However, waiting several weeks, months, or even years for symptoms to resolve can have a significantly negative impact on the patient’s quality of life.
Traditionally, vestibulosuppressant medications have been used to treat vertigo, but they have met with only limited success. Medication may provide minimal relief for some patients, but it is designed to treat the symptom of vertigo, not the underlying cause. Vestibulosuppressant medications can also have undesirable side effects, such as grogginess and sleepiness.1
Vestibular rehabilitation therapy (VRT) is a noninvasive approach that has been used in the past to treat BPPV with limited effectiveness. Through repeated positional and balance exercises, the goal of VRT is to desensitize the balance system to the movements that cause the patient’s feelings of vertigo. The primary drawback to VRT is that it takes several sessions to achieve any result, and the treatment itself induces repeated bouts of vertigo for the patient. Repeated therapy sessions can also be quite costly.1,2
For more than a decade, canalith repositioning techniques have been used to treat BPPV with good success and are now generally considered to be the standard of care. The Epley maneuver and the Semont maneuver, named after their inventors, have both shown high rates of resolution of BPPV when performed correctly. Both procedures involve moving the patient through a series of positions designed to guide the displaced octoconia that cause BPPV into a less sensitive location. The primary difference between the two procedures is that the Semont maneuver uses quick, forceful movement of the patient, whereas the Epley maneuver is gentler, relying on gravity more than inertia to move the octoconia through the canals.
Some experts advocate the use of a mastoid bone oscillator during the repositioning maneuver to assist with freeing trapped octoconia and facilitating their movement through the semicircular canals. A 1995 study by John Li, MD, showed that the use of mastoid vibration during repositioning increased the success rate from 60% (in the nonvibration group) to 92% (in the vibration group).3 The literature since that time has shown mixed results regarding the advantage of adding mastoid bone oscillation.4
Dr. Li believes that using oscillation, with or without a device, can help improve results. Ultimately, it’s a matter of physician preference. He stated, The bottom line is, do you prefer to shake the ketchup or not? Although not mandatory, shaking should work better.
The success of canalith repositioning is measured by the patient’s subjective report of resolution of symptoms and by the physician’s objective observation of the disappearance of nystagmus. The use of infrared goggles and a TV monitor can provide real-time observation of nystagmus as the patient is maneuvered into various positions. The physician can also readily identify changes in the type of nystagmus, which can indicate a change in location of the displaced octoconia, and thus a need to change strategies.
If a rotational nystagmus changes to lateral nystagmus, you know you’ve converted to a horizontal canal problem, said Dr. Li.
Dr. Gianoli added, The use of infrared goggles with a TV monitor greatly improves diagnostic ability and the physician’s ability to target which semicircular canal is affected.
A small percentage of patients may fail noninvasive efforts to correct BPPV or have frequent recurrences of symptoms, requiring repeated procedures. For these patients, surgery may offer the best answer.
Singular neurectomy, or section of the posterior ampullary nerve, has demonstrated high efficacy in resolving vertigo. The surgery, however, is technically difficult, and few surgeons have performed the procedure often enough to have become highly proficient. There is a high risk of sensorineural hearing loss associated with singular neurectomy.
The most common surgical intervention for BPPV is posterior semicircular canal occlusion. The semicircular canal lumen is obstructed with a plug fashioned from bone dust and fibrinogen glue, immobilizing the fluid in the canal. This procedure has shown a high rate of success and is much less technically demanding than the singular neurectomy. The primary risk with posterior semicircular canal occlusion is also hearing loss, but there is a much lower incidence than that associated with singular neurectomy.4
The Epley Omniax
A new treatment is now available through Vesticon, Inc., for individuals with BPPV. John Epley, MD, inventor of the Epley maneuver and principal investigator for Vesticon, has developed a computerized patient positioning apparatus for more effective diagnosis and treatment for patients suffering from vestibular disorders, including BPPV. This apparatus, called the Epley Omniax, can rotate patients through 360 degrees in any plane without their bodies and necks being manipulated and twisted. Because the patient is strapped immobile in the chair, this device can be used to treat patients who may not be amenable to manual manipulation on an examining table, such as the morbidly obese and those with some degree of paralysis or arthritis. The device collects data in real time, including correlating the patient’s spatial orientation with 3D eye movement measurements, and it prints out a report for billing and patient management.
Dr. Epley said of the device, We’ve been able to cure almost 100% of BPPV patients using the Omniax. I haven’t seen the need to do surgery in probably five years.
The Omniax is marketed by Vesticon and is already being tested at six sites in the United States and one site in Australia.5
Dr. Epley concluded that probably the most important thing that otolaryngologists can do is hone their ability to recognize and interpret nystagmus. He suggested that physicians who regularly see patients with BPPV might benefit from taking a course on diagnosis and treatment of the condition.
He stated, The nystagmus characteristics tell you quite a bit about what’s going on in the inner ear, and we’re learning more and more how to interpret that information and put it to good use.
- Li JC, Epley J. Benign paroxysmal positional vertigo. eMedicine. Available at www.emedicine.com/ENT/topic761.htm . Accessed July 5, 2007.
- University of Maryland Medical Center. Benign paroxysmal position vertigo (BPPV). Available at www.umm.edu/otolaryngology/bppv.html . Accessed July 19, 2007.
- Li JC. Mastoid oscillation: a critical factor for success in canalith repositioning procedure. Otolaryngol Head Neck Surg 1995;113:712-20.
- Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003;169:681-93.
- Vesticon Web site: www.vesticon.com . Accessed July 10, 2007.
©2008 The Triological Society