Pavilion Health Today
Supporting healthcare professionals to deliver the best patient care

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo is a disorder arising in the inner ear. Its symptoms are repeated episodes of positional vertigo.

Benign paroxysmal positional vertigo (BPPV) is a disorder arising in the inner ear. Its symptoms are repeated episodes of positional vertigo – a spinning sensation caused by changes in the position of the head.

BPPV is the most common cause of the symptoms of vertigo. The term paroxysmal is used because characteristically this condition is episodic and not continuous, furthermore as the feeling of vertigo appears to be precipitated in specific positions it is called positional even though the symptoms are elicited by rotational movement of the head rather than by the final position of the head.1I

t was first described by Barany in 1921 and Dix and Hallpike demonstrated the geotropic and torsional nystagmus with provocation to localise the pathology in the proper ear in 1952. It usually leads to patients complaining of vertigo on extending or turning the neck, getting up or lying down or rolling over in the bed.2 A characteristic of BPPV is absence of any hearing loss in association with dizziness though in the case of the elderly population degenerative processes may cause a simultaneous alteration of auditory systems causing some deafness.3

The estimated incidence of BPPV is between 10.7 to 64 per 100,000 per year, and it increases with age.4,5 A German study has found a lifetime prevalence of 2.4% with a cumulative incidence approaching 10% by age 80.6 It is the commonest cause of vertigo in adults and by the age of 70, 30% of individuals have had the disorder at least once.7,8 BPPV and dizziness are associated with falls and falls represent a significant risk of serious injury and death.9 Treatment of the BPPV by particle repositioning manoeuver (PRM) improves the patient condition and reduces the incidence of falls in the elderly.10

Pathophysiology of benign paroxysmal positional vertigo

The pathology of BPPV originates in the inner ear that contains the three semicircular canals (SCC) oriented perpendicular to each other. The cupula is the structure within the SCCs, which helps in the detection of movement. The exact pathophysiology of BPPV is not yet completely understood but the accepted mechanisms are cupulolithiasis11 and canalithiasis.12

Schukencht postulated that basophilic particles or densities adherent to the cupula rendered the posterior SCC sensitive to gravity causing persistent nystagmus and dizziness when a patient is tilted backward. This is also the reason that the vast majority of BPPV patients suffer from disease originating in the posterior canal.

Epley in 1980 published his theory of canalithiasis causing benign paroxysmal positional vertigo , which put forward the idea that the symptoms of this condition are more correctly explained by presence of free moving densities (canaliths) in the posterior SCC. This model is better at explaining the delay, transient nystagmus and improvement of symptoms with change in posture, which is characteristic of this pathology, and has been further corroborated by findings of free densities in the posterior SCC at surgery.13

Various age-related changes in the vestibular system increase the susceptibility of the elderly to develop dizziness. Some of these are the age-related loss of hair cells within the cristae ampullaris of the semicircular canals and the maculae of the saccules and urtricle,14 the reduction of the number of primary vestibular neurons within Scarpa’s ganglion15 and decrease in the number of secondary vestibular neurons within the vestibular nuclei.16 The ageing hypothesis of BPPV proposes that the detachment of otoconia from the macula is the result of degenerative changes in the utricle, possibly due to chronic ischaemia. As the inner ear arteries are end arteries any decrease in blood flow can have a profound effect. There are various triggering factors that have been implicated in the causation of BPPV,17,18.

Presentation and diagnosis

Common situations that provoke vertigo in BPPV are when patients roll into a lateral position in the bed, look upward, or bend forward. The dizziness is often associated with nausea, with or without vomiting. The episode usually lasts for only 10 to 20 seconds and recurs. This is a self-limiting disorder but can persist for several weeks or even years. The presentation in the elderly may be more gradual and sudden deterioration in symptomatology may be caused by decompensation of pre-existing peripheral vestibular pathology.

There are no laboratory or imaging tests to diagnose BPPV. Confirmation of this problem therefore rests with history and physical tests. Screening questions that give a strong indication of the possibility of BPPV can also be used and the presence of a spinning sensation without lightheadedness has a 56% sensitivity for indicating BPPV.19

Sometimes the history itself is very suggestive of the diagnosis and if the patient reports the appearance of the distressing symptoms such as – turning in bed at night, or hanging the washing on the line, or looking under the car – then BPPV should be high on the differential diagnosis list.20

Other questions that can be asked to elicit indicators towards the diagnosis of BPPV are:1. Do you feel dizzy while turning in the bed?2. Do you feel dizzy when you turn your head quickly?3. Do you feel dizzy when you lift your head or upper part of the body off the pillow?4. Do you veer towards one side on walking?5. Do you have to hold on to something when you turn quickly?Among the various physical tests described in literature the one described by Dix and Hallpike21 in 1952 remains most common. The test involves seating the patient on a couch, turning their head by 45 degrees to one side and then bringing them quickly to a position 30 degrees below horizontal. The procedure, if negative on one side is then repeated by turning the head to the other side.

For a positive test the patients’ eyes are observed for the appearance of the typical geotropic and torsional nystagmus. There is a latent period of 5-10 seconds before the nystagmus appears and this is nearly always preceded by an appearance of distress. The nystagmus should be reversed on returning the patient to a sitting position. Even though the sensitivity of this test in diagnosing BPPV is in the range of 50% to 78%,22,23 this remains the gold standard in confirming the presence of BPPV. There are video examples of this test easily available on the internet.24

In the elderly the Dix-Hallpike manoeuver can be modified to fit the patient’s situation. The patient need not be moved vigorously as the movement of canaliths is dependent on gravity and not on acceleration of the body. The hyperextension of the neck can also be limited as symptoms can usually be induced by simple turning in the bed. Further help can be provided by having additional assistants to help position the patient and in severe neck or back problems, specialised equipment may be needed.25 Local experience at our institution suggests that using a hospital bed in the head down position facilitates doing the manoeuver, even in the frail elderly.

Benign paroxysmal positional vertigo and falls

Falls is one of the geriatric giants, causing severe morbidity and mortality. It is the sixth largest cause of death in people aged 65 and above,26 and is responsible for 70% of accidental deaths in those aged 75 and over.27 The causes of falls are legion but one of the complaints that patients frequently present with is dizziness. Depending on the cutoff age of the study participants, type of symptoms studied, and the selection of the participants, it is estimated that half to third of the elderly (>65 years of age) have experienced some form of dizziness28,29 and in the very elderly (>85 years of age) this rises to about half.30 Falls are complex phenomena involving neurological, biomechanical and other factors31 and older adults with a history of dizziness imbalance and similar symptoms are at a higher risk of falling.32,33,34 Balance disorder and dizziness were among the top three causes of falls in the meta-analysis of 12 large studies done in 2006.35

Dizziness has always been hard to quantify, leading to the suggestion that it should be viewed, in the elderly, as a mutifactorial geriatric syndrome involving many different symptoms and originating from many different systems including sensory, neurologic and cardiovascular. In one of the studies, in 80% of the patients with dizziness the cause could be ascribed to cardio-vascular, peripheral vestibular or psychiatric diseases36 and among the peripheral vestibular disorders, BPPV is the commonest finding. Katsarkas reporting in Geriatrics quoted a figure of 40% of patients older than 70 years being diagnosed with BPPV.37

Management of benign paroxysmal positional vertigo

Once the diagnosis of BPPV is made there are various possibilities regarding treatment. These range from doing nothing to subjecting the patient to various surgical procedures.1 ObservationAs BPPV is a self-limiting condition, watchful waiting can be done to let the disease run its course. The advantages of this approach are that the patient is spared being put on more medications (polypharmacy increasing the risk of falls), or being subjected to potentially unpleasant manoeuvers. This approach can though, lead to weeks or months of discomfort for the patient and increases the danger of a fall in the elderly patient while waiting for the resolution of symptoms.

Medications

Vestibulo suppressant medications are not usually helpful as they only mask the problem and are associated with side effects such as drowsiness and extrapyramidal symptoms. In a small (n=20) double blinded RCT comparing placebo to diazepam (5mg, tds) or lorazepam (1mg, tds), no difference in dizziness symptom was noted over a period of four weeks.38

Vestibular rehabilitation (VR)

This comprises exercises customised according to the patient complaint, clinical aspects and vestibulometry findings with modifications according to the clinical evolution of the patient during treatment. Though these have been shown to produce improvement in the patients quality of life irrespective of gender or age,39 the prolonged nature of this approach makes it unsuitable for the elderly population.4

Particle repositioning manoeuvres (PRM)

This is the mainstay of the treatment and can actually be done in the same sitting as the diagnosis. The Epley particle repositioning is effective treatment for BPPV and has a success rate of between 70% to 100%.40 This can be carried out by doctors, physiotherapists, occupational therapists or chiropractors. Similar precautions and modifications as required for the Dix-Hallpike test are used for the modified Epley manoeuvers. The procedure may need to be repeated to ensure resolution of symptoms and absence of positioning nystagmus. There are other PRMs like Semont manoeuver but due to the vigorous side to side movements involved, they are less suitable for the very elderly population. In one trial with comparatively elderly patients (mean age 74 years) the calcium channel blocker flunarizine was compared to Semont’s liberatory manoeuvre or no therapy. At the six month follow up the rates for asymptomatic patients with negative Dix-Hallpike test was 94% for Semont’s manoeuver, 58% for flunarizine and 34% for no therapy.41

Surgery

In patients who continue to be distressed by BPPV in-spite of repeated attempts at repositioning the otoliths surgical procedures like labyrinthectomy, posterior canal occlusion, singular neurectomy, vestibular nerve section or transtympanic aminoglycoside application can be tried.These procedures are invasive and associated with complications like hearing loss and facial nerve damage. Furthermore, a proportion of the elderly patients will be unsuitable for surgery due to the presence of comorbidities.

Treatment characteristics in the older patient

It has been shown that characteristics and treatment responsiveness of BPPV in elderly patients are similar to the general population,42 though there may be a less favorable final functional outcome due to the presence of multiple comorbidities. The multifactorial nature of the reasons for falls in the elderly means that other pathologies like orthostatic hypotension may coexist and need to looked for along with BPPV.

The duration of vertigo before PRM is an indicator for the likelihood of residual dizziness being present after treatment43 44 as is age and anxiety.

A study in Brazil in 2009 showed that all individuals -adults and elderly; men and women significantly benefit from treatment of BPPV,45 while another study the next year looked at 121 patients with BPPV (age range 65 to 89 years) who underwent particle repositioning manoeuvers showed a statistically significant reduction in the number of falls at one year.46

Conclusion

Benign paroxysmal positional vertigo  is the commonest cause of vertigo in the elderly with the incidence rising with age. It is caused by canaliths in the semicircular canals in the inner ear and presents with symptoms of dizziness on particular movement of the head. Various triggering factors can worsen or bring on the symptoms. It causes an increase in incidence of fall in the elderly.

The diagnosis of BPPV depends on typical history and observation of reversible, geotropic and torsional nystagmus on Dix-Hallpike test.There are various modalities of treatment available but the ease of use of the PRMs and the side effects of the other treatments make Epley, or less commonly the Semont manoeuver, the treatment of choice. The consideration of BPPV as a cause of dizziness, its diagnosis with provocative tests and treatment with PRMs leads to an improved quality of life and reduction in the incidence of falls in these patients. BPPV should therefore be actively sought for as a cause of dizziness and falls in the elderly patient and its presence should prompt the clinician to institute or arrange for treatment of this common condition.


Dr Saurabh Shandilya, ST6 Geriatrics, Wrexham Maelor Hospital

ales)
Prakash, A, Consultant Physician (Geriatrics), Wrexham Maelor Hospital

Conflict of interest: none declared


References

1 Furman JM, Cass SP: Benign paroxysmal positional vertigo. N Engl J Med 1999, 341:1590-1596

2 L. Pollak et al. Approach to Benign Paroxysmal Positional Vertigo in Old Age. IMAJ 2005;7: 447-450

3 Moreno NS et al. Audiologic features of elderly with Benign Paroxysmal Positional vertigo. Braz J Otorhinolaryngol. 2009;75(2):300-4

4 Kanemasa M et al. Epidemiological studies on Benign Paroxysmal Positional Vertigo in Japan. Acta Otolaryngol (Stockh) 1988:Suppl 447; 67-72

5 Froehling DA et al. Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota. Mayo Clin Proc 1991; 66: 596-601

6 M von Brevern, et al. Epidemiology of Benign paroxysmal positional vertigo: a population based study. J.Neurol Neurosurg Psychiatry. 2007; 78:710-715

7 Gananca MM et al. Diagnosis and treatment of benign positional paroxysmal vertigo. New York: Oxford; 1996. p 328-39

8 Fetter M – Vestibular System Disorders. In: Herdman, S.J. (ed.) – Vestibular Rehabilitation. Philadelphia: Davis; 1994. p. 80-9.

9 Oghalai JS et al. Urecognized benign paroxysmal positional vertigo in elderly patients. Otolaryngol Head Neck Surg 2000;122:630-4

10 Gananca FF et al. Elderly falls associated with benign paroxysmal positional vertigo. Braz J Otorhinolaryngol. 2010; 76(1):113-20

11 Schuknecht HF : Cupulolithiasis. Arch Otolaryngol 1969;90:765-78

12 Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. Sep-Oct 1980;88(5):599-605.

13 Parnes LS, Mc Clure JA. Free-floating endolymph particles: a new operative finding during posterior semicircular canal occlusion. Laryngoscope. 1992 Sep;102(9):988-92

14 Ishiyama G. Imbalance and vertigo: the aging human vestibular periphery. Semin Neurol 2009. 29(5): 491-9

15 Ishiyama A. Unbiased quantification of the microdissected human Scarpaʼs ganglion neurons. Laryngoscope 2004. 114(8):1496-9

16 Age-Related change of the neuronal number in the human medial vestibullar nucleus: a stereological investigation. J Vestib Res 2001-2002;11(6)357-63.

17 Ana Paula do Rego Andre et al. Conduct after Epleyʼs maneuver in elderly with posterior canal BPPV in the psoterior canal. Arq Neuropsiquiatr. 2000;59:466-70

18 Ana Paula do Rego Andre et al. Conduct after Epleyʼs maneuver in elderly with posterior canal BPPV in the psoterior canal. Rev.Bras Med Cad Otorrinol. 57(12) Dez 2000a

19 Oghalai JS et at. Unrecognized benign paroxysmal positional vertigo in elderly patients. Otolaryngol Head Neck Surg 2000;122:630-4

20 GM Halmagyi. Diagnosis and management of vertigo. Clin Med 2005; 5:159-65

21 Dix MR and Hallpike CS. The Pathology, Symptomatology and Diagnosis of Certain Common Disorders of the Vestibular System. Proc R Soc Med. 1952 June; 45(6): 341€“354.

22 Blakley BW et al. A randomized, controlled assessment of the canalith repositioning maneuver. J Otolaryngol 1978;7:320-30

23 Froehling DA et al. The Canalith Repositioning Procedure for the Treatment of Benign Paroxysmal Positional Vertigo: A Randomized Controlled Trial. Mayo ClinicProc 1991;66:596-601

24 http://www.youtube.com/watch?v=vRpwf2mI3SU

25 Barin K et al. Dizziness in the elderly. Otolaryngol Clin N Am 44(2011) 437-54

26 Ganaca FF et al. National campaign to prevent falls in the elderly population September 27. Ann Emerg Med. 1997; 30:480-92

27 Fuller GF. Falls in the elderly. Am Fam Physician. 2000; 61: 2159-68

28 Tinetti ME et al. Dizziness among older adults: a possible geriatric syndrome. Ann Intern Med 2000; 132 (5): 337-44

29 Sloane PD et al. Persistent dizziness in geriatric patients. J Am Geriatr Soc 1989; 37(11): 1031-8

30 Jonsson R et al. Prevalence of dizziness and vertigo in an urban elderly population. J Vestib Res 2004: 14 (1): 47-52

31 Barin K et al. Dizziness in the elderly. Otolaryngol Clin N Am 44 (2011) 437-454

32 Graafmans WC et al. Falls in the Elderly: A Prospective Study of Risk factors and Risk Profiles. Am J Epidemiol 1996; 143(11):1129-36

33 OʼLoughlin JLet al. Falls among the elderly: distinnuishing indoor and outdoor risk factors in Canada.J Epidemiol Community Health 1994; 48(5): 488-9

34 Stel VS et al. A classification tree for predicting recurrent falling in community dwelling older persons. J Am Geriatr Soc 2003; 51(10):1356-64

35 Rubenstein LZ et al. Falls and their prevention in elderly people: what does the evidence show? Med Clin North Am. 2006 Sep;90(5):807-24

36 Maarsingh OR et al. Causes of persistent dizziness in elderly patients in primary care. Ann Fam Med 2010;8(3): 196-205

37 Katsarkas A. Dizziness in aging: the clinical experience.Geriatrics 2008; 63(11): 18-20

38 McClure JA, Willett JM: Lorazepam and diazepam in the treatment of benign paroxysmal vertigo. J Otolaryngol 1980, 9:472€“477.

39 Patatas OHG et al. Quality of life of individuals submitted to vestibular rehabilitation.Braz J Otorhinolaryngol. 2009; 75(3): 387-94

40 Epley JM. Positional vertigo related to semicircular canalithiasis. Otolaryngol Head Neck Surg 1995;112:154-61

41 Salvinelli F et al. Treatment of Benign Positional Vertigo in the Elderly: A Randomized Trial. Laryngoscope. 2004;114:827-831

42 Pollak L et al. Approach to Benign Paroxysmal Positional Vertigo in Old Age. IMAJ 2005; 7: 447-450

43 Seok JI et al. Residual Dizziness after Successful Repositioning Treatment in Patients with Benign Paroxysmal Positional Vertigo. J Clin Nerrol 4:107-110

44 Stambolieva K et al. Postural stability in patients with different durations of benign paroxysmal positional vertigo. Eur Arch Otorhinolaryngol 263:118-122

45 Patatas OH et al. Quality of life of individuals submitted to vestibular rehabilitation. Braz J Otorhinolaryngol. 2009; 75(3):387-94

46 Gananca FF et al. Elderly falls associated with benign paroxysmal positional vertigo. Braz J Otorhinolaryngol. 2010;76(1):113-20

This website uses cookies to improve your experience. We'll assume you're ok with this, but you can opt-out if you wish. Accept Read more ...

Privacy & Cookies Policy