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Positional Vertigo: what you need to know

TGIF folks!


My apologies for missing a blog post last Friday, but I was out of commission for about 3 days post second dose Moderna vaccination with a robust immune response of fever, headaches & body aches! Honestly, it felt as though I had been hit by a SLEDGE HAMMER! Thanks to Panadol and lots of sleep (skipping meals), I lost 4 kg and feeling much better now! So it seems that many blog readers have asked re positional vertigo, so here goes!


Positional Vertigo: is still the most common cause of vertigo till today!


What is BPPV?


Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo — the sudden sensation that you are spinning or that the inside of your head is spinning. BPPV causes brief episodes of mild to intense dizziness. It is usually triggered by specific changes in your head's position eg the most typical is the HAIR SALON / shampoo manouver when your hair stylist tilts you back to wash & shampoo your hair and suddenly the room is spinning!


Symptoms of BPPV:


The signs and symptoms of benign paroxysmal positional vertigo (BPPV) include:

  • Dizziness

  • A sense that you or your surroundings are spinning or moving around (Vertigo)

  • A loss of balance or unsteadiness

  • Nausea

  • Vomiting (rarely)

Please note:


Loss of consciousness / syncope / fainting are NOT signs of BPPV; if you experience such symptoms, please seek medical attention as soon as possible, as they may be warning signs of something more serious eg an impending stroke or Vertebro-Basilar Insufficiency (VBI) or a reduced blood circulation to the posterior brain 🧠 or what you may have heard of as a Transient Ischaemic Attack (TIA).


What causes BPPV?


Well, that's a great question:

Often, there's no known cause for BPPV. so we use the term idiopathic BPPV. Also, it becomes increasingly more common as we age. So for your elderly parents or relatives, do look out for BPPV symptoms as it is eminently treatable and may prevent falls & injuries which cause much pain & morbidity.


Sometimes, BPPV is associated with a minor to severe blow to your head.

For example, I had a patient who was a semi professional soccer ⚽️ player; whenever he headed the ball, he would then experience symptoms of BPPV. Eventually I taught him how to do his own physiotherapy... and he was fine!


Less common causes of BPPV include disorders that damage your inner ear or, rarely, damage that occurs during ear surgery or long periods positioned on your back, such as prolonged procedures in a dentist chair. BPPV also has been associated with migraines.


How is it diagnosed?


We make the diagnosis based on a good medical history and ENT examination, and in my practice, a good otological check for your hearing and balance systems. For my clinic, we perform a detailed check into your ears and examine the ear drum in detail with an otoscope or microscope. 🔬 This is to exclude any other causes of the giddiness eg ear infection.


Oto-microscopy in progress at EUANs ENT Surgery & Clinic


Finally, we confirm the diagnosis of BPPV by reproducing the signs & symptoms by performing the Dix Hall Pike manouver. In this manouver, your doctor will support your neck as he dips you downwards and backwards with your head tilted at 45 degrees....akin the the hair salon shampoo position!


Illustration from Research Gate showing the Dix-Hallpike manouver

A positive Dix-Hallpike test consists of a burst of nystagmus (jerking of the eyes). In the classic posterior canal BPPV, the eyes jump upward as well as twist so that the top part of the eye jumps toward the down facing side.


Don't worry or panic! The spinning sensation is temporary and will fade off. Also, you are safely lying down on the doctor's couch so you won't fall off!


How can we treat it?


Benign paroxysmal positional vertigo may go away on its own within a few weeks or months. But, to help relieve BPPV sooner, your doctor, audiologist or physical therapist may treat you with a series of movements known as the Canalith Repositioning Procedure (CRP)


The Canal Re-Positioning Procedure (CRP)


This CRP maneuver was first described by an ENT Doctor in USA whom I met personally back in the 1990's in Colorado at a conference on Giddiness, namely Dr John Epley. It was a privilege to learn from Dr Epley personally, and to be able to benefit many patients with BPPV.


Performed in your doctor's office, the canalith repositioning procedure (CRP) consists of several simple and slow manouvers for positioning your head. The goal is to move particles from the fluid-filled semicircular canals of your inner ear into a tiny bag-like open area (vestibule) that houses one of the otolith organs in your ear, where these particles don't cause trouble and are more easily resorbed.


Each position is held for about 20 to 30 seconds after any symptoms or until abnormal eye movements stop. This procedure usually works after one or two treatments.


Will it recur?


Recurrence of BPPV is not uncommon, so if your symptoms return, do visit your GP or ENT Specialist. For my patients, I usually also teach and prescribe some other simple balance exercises to do at home, on the chair or on the bed.


These exercises are good to motivate you to be pro-active and in also getting better!


Here are some useful references on BPPV which you may want to have a read:


References:


1. J Neurosci Rural Pract. 2011 Jan-Jun; 2(1): 109–110. Benign Paroxysmal Positional Vertigo

2. von Brevern M, Radtke A, Lezius F, Feldmann M, Ziese T, Lempert T, et al. Epidemiology of benign paroxysmal positional vertigo: A population based study. J Neurol Neurosurg Psychiatry. 2007;78:710–5. [PMC free article] [PubMed] [Google Scholar] 3. Fife D, FitzGerald JE. Do patients with benign paroxysmal positional vertigo receive prompt treatment? Analysis of waiting times and human and financial costs associated with current practice. Int J Audiol. 2005;44:50–7. [PubMed] [Google Scholar] 4. Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008;139:S47–81. [PubMed] [Google Scholar] 5. Jeong SH, Choi SH, Kim JY, Koo JW, Kim HJ, Kim JS. Osteopenia and osteoporosis in idiopathic benign positional vertigo. Neurology. 2009;72:1069–76. [PubMed] [Google Scholar] 6. Prokopakis EP, Chimona T, Tsagournisakis M, Christodoulou P, Hirsch BE, Lachanas VA, et al. Benign paroxysmal positional vertigo: 10-year experience in treating 592 patients with canalith repositioning procedure. Laryngoscope. 2005;115:1667–71. [PubMed] [Google Scholar] 7. Baloh RW, Yue Q, Jacobson KM, Honrubia V. Persistent direction-changing positional nystagmus: Another variant of benign positional nystagmus? Neurology. 1995;45:1297–301. [PubMed] [Google Scholar] 8. Lopez-Escamez JA, Molina MI, Gamiz M, Fernandez-Perez AJ, Gomez M, Palma MJ, et al. Multiple positional nystagmus suggests multiple canal involvement in benign paroxysmal vertigo. Acta Otolaryngol. 2005;125:954–61. [PubMed] [Google Scholar] 9. Radtke A, von Brevern M, Tiel-Wilck K, Mainz-Perchalla A, Neuhauser H, Lempert T. Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure. Neurology. 2004;63:150–2. [PubMed] [Google Scholar] 10. Yimtae K, Srirompotong S, Srirompotong S, Sae-Seaw P. A randomized trial of the canalith repositioning procedure. Laryngoscope. 2003;113:828–32. [PubMed] [Google Scholar] 11. Hain TC, Helminski JO, Reis IL, Uddin MK. Vibration does not improve results of the canalith repositioning procedure. Arch Otolaryngol Head Neck Surg. 2000;126:617–22. [PubMed] [Google Scholar]




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