Benign paroxysmal positional vertigo

BPPV is a common type of acute vertigo that is induced by changing head position—particularly tilting the head backwards, changing from a recumbent to a sitting position or turning to the affected side. Characteristic features:

• It affects all ages especially the elderly.
• The female to male ratio is 2:1.
• It recurs periodically for several days.
• Each attack is brief, usually lasts 10-60 seconds, and subsides rapidly.
• Attacks are not accompanied by vomiting, tinnitus or deafness (nausea may occur).
• In one large series 17% were associated with trauma, 15% with viral labyrinthitis while about 50% had no clear predisposing factor other than age. One accepted theory of causation is that fine pieces of debris that are loose in the labyrinth settle on the bottom of the ear and generate endolymphatic movement. It may also be a variation of cervical dysfunction.
• Diagnosis is confirmed by head position testing. (From a sitting position the patient’s head is rapidly taken to a head-hanging position 30° below the level of the couch—do three times, with the head (1) straight, (2) rotated to the right, (3) rotated to the left. Hold on for 30 seconds and observe the patient carefully for vertigo and nystagmus. There is a latent period of a few seconds before the onset of the symptoms—
• Tests of hearing and vestibular function are normal.
• There is usually spontaneous recovery in weeks (most return to regular activity after 1 week).
• Recurrences are common: attacks occur in clusters.

Management

• Give appropriate explanation and reassurance.
• Drugs are not recommended.

Positional vestibular exercises

Most patients appear to benefit from exercise such as the Brandt and Daroff procedure or the Cawthorne Cooksie exercises that consist essentially of repeatedly inducing the symptoms of vertigo. Rather than resorting to avoidance measures the patient is instructed to perform positional exercises to induce vertigo, hold this position until it subsides, and repeat this many times until the manoeuvre does not precipitate vertigo. The attacks then usually subside in a few days.

Surgical treatment

Rarely surgical treatment is required; it involves occlusion of the posterior semicircular canal rather than selective neurectomy.