By far, benign paroxysmal positional vertigo (abbreviated as BPPV) is the most common type of all vertigo disorders. The symptoms of the disease are mainly characterized by a brief spinning-like sensation that usually lasts less than one minute and is usually induced after a change in head position, such as lying down or getting up, turning over in bed and tilting the head back or forward.
Many patients experience episodes of vertigo with nausea and sometimes vomiting. the etiology of BPPV is unclear and may be related to head trauma, prolonged reclining, and various inner ear disorders. There are frequent spontaneous remissions and recurrences, and the probability of recurrence within a year is about 15%. During daily activities, patients are prone to falls and injuries.
The prevalence of BPPV is significantly higher in the elderly population and in the female population, with a high prevalence in the age group of 50-60 years and a male to female ratio of 2-3:1.
When the patient’s head position is suddenly changed, it can cause displacement of otolith debris in the semicircular canal, resulting in some kind of rotation-like position illusion. Since the posterior semicircular canal is most susceptible to gravity, BPPV caused by otoliths in the posterior semicircular canal is the most common, accounting for 60-90% of all cases.
Clinical points
1.BPPV is by far the most common type of all vertigo diseases, mainly manifesting as a transient rotation-like sensation, induced by head position change.
2. The diagnosis of posterior semicircular canal BPPV must be based on nystagmus excitation test: when the patient performs DixCHallpike test, upward rotational nystagmus can be seen when the head is turned to the side, and the nystagmus fast phase is directed to the ground.
3. When the DixCHallpike test is performed on patients with horizontal hemianopia BPPV, groundward nystagmus or backward nystagmus is seen when the patient lies flat and the head is turned to the side.
4. Otolithic manipulation is effective for BPPV (e.g., Epley’s manipulation is effective for posterior semicircular canal type BPPV).
Diagnosis
It was found by physical examination that positional nystagmus was visible in more than 70% of patients with BPPV, and different maneuvers could be chosen to induce resetting depending on the involved semicircular canals.
Figure 1. The DixCHallpike maneuver was used to induce nystagmus in a patient with right posterior semicircular canal type BPPV.
The patient was seated (A) with the head rotated 45 degrees to the right (B), and after maintaining the head position, the patient’s upper body was lowered and laid flat on the bed with the head suspended 20 degrees under the edge of the bed (C). Upward rotational nystagmus was induced, and eye movements were fast phased to the right (D).
1. Posterior hemiretinal type
The DixCHallpike maneuver was applied to patients with posterior semicircular canal type BPPV, and typical nystagmus could be induced (see Table 2 and Figure 1). When the otolith debris in the posterior semicircular canal is dislodged from the jugular cap, the endolymph follows the flow, thus stimulating the posterior semicircular canal. The nystagmus caused by this condition is an upward rotational nystagmus with rapid eye movements phase to the ground (the patient’s head is turned sideways to one side).
The nystagmus usually appears after 2-5 seconds and disappears within 1 minute (usually 30 seconds), and when sitting up the nystagmus is in the opposite direction. When the test is repeated, a decrease in nystagmus amplitude will occur due to eye fatigue. The same form of nystagmus can be induced if the otolith is adhered to the potbelly cap, but for a longer duration.
Performing the DixCHallpike maneuver test on a patient that induces the above form of nystagmus can be an important diagnostic criterion for posterior hemianopia BPPV. However, close to a quarter of patients can induce only mild nystagmus or even no nystagmus. In such patients, if the clinical symptoms are compatible, there is still a good outcome.
2.Horizontal semicircular canal type
The diagnosis of horizontal hemianopsia BPPV is often made by the supine head turn test, in which the patient is placed supine and the patient’s head is rotated rapidly by 90 degrees to one side (see Table 2). Horizontal nystagmus occurs when the head is turned to one side, with the fast phase of the nystagmus directed toward the ground (groundward nystagmus) or toward the ceiling (backward nystagmus).
Identifying the affected side is the first task in the proper treatment of horizontal nystagmus BPPV. If the nystagmus is more pronounced when the head is turned to the left than when it is turned to the right, the left side is the affected side.
3. Anterior hemianopia
Anterior semicircular canal BPPV is rare and little is known about its pathogenesis. It is characterized by an inconspicuous nystagmus, often manifesting as a mild rotational nystagmus with fast eye movements toward the affected side. When a patient presents with this nystagmus, a central injury should be considered, although central lesions are difficult to detect.
Treatment
Patients with BPPV often resolve spontaneously without treatment. However, otolithic manipulation often provides rapid and effective treatment of BPPV, and medications are primarily used to relieve more severe nausea or vomiting symptoms. Surgical treatment such as posterior potygapophyseal nerve amputation and hemicrania occlusion are rarely used and may be considered when the patient’s symptoms are particularly severe and uncontrollable and ineffective for manual repositioning.
Figure 2. Epley otolith repositioning for right posterior semicircular canal BPPV.
After the disappearance of the nystagmus induced by the DixCHallpike maneuver (A, B and C), the head is rotated 90 degrees to the healthy side (left side) (D) so that the otolith is transferred to the side of the common foot, and if nystagmus occurs at this point, it is in the same direction as the nystagmus induced by the previous DixCHallpike maneuver. The head continues to rotate 90 degrees downward and the body also rotates 90 degrees in the same direction, with the patient’s face facing the ground and the body lying on its side on the healthy side (E); the otolith migrates in the same direction. The patient then sits up (F), and the otolith falls back into the vestibule through the common foot. Each position should be held until the nystagmus and vertigo symptoms disappear, usually not less than 30 seconds.
1. Posterior semicircular canal type
Epley otolith manipulation aims to move the otolith in the posterior semicircular canal back into the vestibule (see Figure 2). During the resetting process, the otolith is moved through the canal following the various manipulation steps and eventually back into the vestibule. Each position should be held, usually for at least 30 seconds, until the nystagmus or vertigo disappears. The success rate for one Epley maneuver resetting is approximately 80%, increasing to 92% for four resets.
Meta-analysis of five randomized controlled trials showed that patients with posterior semicircular canal BPPV treated with Epley manipulation showed significant improvement in vertigo symptoms and nystagmus compared to the sham manipulation and negative control groups. Some clinicians advocate vibrating the patient with a portable vibrator at the affected mastoid during Epley manipulation or suggest limiting the patient’s head and body movements after manipulation, but there is no evidence to support these recommendations. However, maintaining a seated position for 15 minutes after manipulation seems to be justified.
Careful observation of the patient’s nystagmus pattern when performing the Epley maneuver can help determine the success of the maneuver. Positional nystagmus occasionally reappears when the patient’s head is rotated back 90 degrees from the affected side. One study reported that in 99 patients, the original nystagmus disappeared after one or two Epley maneuvers, but all of these patients had a subsequent reoccurrence of nystagmus in the same direction as before.
In another 15 patients, the direction of the nystagmus changed from the original direction after repositioning, but three of them healed. However, these patients did not heal, but their symptoms did improve, and after all, the otolith came out of the posterior hemianopia somewhat.
Figure 3. Semont repositioning for right posterior semicircular canal type BPPV.
The patient is asked to sit upright (A) and then lie down to the healthy side (B). The patient’s head and body were made to turn 180 degrees rapidly from the affected side to the healthy side (C), at which time the head was turned to the healthy side (left side). Finally, the patient is allowed to sit up with the head back in the forward position (D). Each position should be held until the nystagmus and vertigo symptoms disappear, usually no less than 2 minutes.
Semont repositioning can also be used to treat posterior semicircular canal type BPPV (see Figure 3). To effectively evacuate the otolith particles, the patient is instructed to turn rapidly 180 degrees from the affected side to the healthy side within 1.3 seconds. When the patient cannot tolerate the Epley maneuver due to difficulty in neck rotation, the Semont repositioning method can be chosen. As with the Epley maneuver, the Semont repositioning method is validated by the presence of nystagmus to the affected side when the second position is performed.
Both methods may have to be repeated several times to achieve the desired effect, so patients can perform them repeatedly at home until symptoms improve significantly. The results of a randomized controlled trial showed that patients had a 95% success rate in repositioning themselves using the Epley method and 58% using the Semont method. It has been suggested that in clinical practice, patients who reset themselves with proper guidance have significantly better results than passive resetting.
Patients may experience nausea, vomiting, and vertigo during the repositioning process, and many patients experience imbalance and transient dizziness during head movement after repositioning, which may last for several days or even longer, even if the reposition is successful at that time. Other patients may experience transient vertigo a few minutes after the reset is completed.
If the otolithic particles fall out of the posterior semicircular canal and then into the horizontal semicircular canal during the resetting process, the posterior semicircular BPPV is converted to horizontal semicircular BPPV, which is uncommon and occurs in less than 5% of cases. When this happens, we can use other repositioning techniques to treat horizontal semicircular canal BPPV, as follows.
2.Horizontal semicircular canal type
There are two types of horizontal semicircular canal BPPV – groundward nystagmus and backward nystagmus. The former is usually treated by the tumbling method, in which the patient is asked to lie on the affected side – supine – healthy side – prone, and roll 270 degrees continuously, so that the otolith eventually moves back to the vestibule from the horizontal semicircular canal type.
Another repositioning method is called Vannucchi forced lateral position therapy, in which the patient is instructed to lie on the healthy side continuously for 12 hours. This method is suitable for patients with severe symptoms that are easily aggravated by changes in head position and for patients who cannot identify the side of the lesion.
If the patient’s symptoms do not improve significantly after 12 hours of lying on the side, then a change to the other side for 12 hours can be tried. An alternative method, the Gufoni repositioning method, is also available.
Ask the patient to lie down quickly on the healthy side for 1 to 2 minutes until the nystagmus disappears, then rotate the head rapidly downward by 45 degrees, hold it for 2 minutes and immediately help the patient sit up.
Horizontal hallux valgus nystagmus dorsalis BPPV is caused by otolith debris attached to the cap of the potbelly or floating otolith debris in the forearm of the horizontal hallux valgus near the cap of the potbelly. The corresponding repositioning method is aimed at dislodging and transferring these otolith fragments into the posterior arm of the horizontal semicircular canal (see Table 2). The repositioning methods that can be used in this type of patient are the head shake method, the modified Semont method, and the Gufoni method.
In the Gufoni maneuver, the patient is instructed to sit upright with the back and head straight, lie down quickly to the affected side, hold the position for 1 to 2 minutes until the patient’s nystagmus disappears or is significantly reduced, then quickly rotate the head upward 45 degrees, hold for 2 minutes, and have the patient sit up slowly. The maneuver is designed to shift the otolith debris at the cap of the long arm of the horizontal semicircular canal pot belly to a more posterior position so that the otolith may fall back into the vestibule, and even if it does not, it can then be combined with the Gufoni maneuver to assist in the treatment.
Related Guidelines
The American Academy of Neurology published clinical practice guidelines in 2008 for the Spley repositioning method recommended by the American Academy of Otolaryngology, Head and Neck Surgery for the treatment of posterior semicircular canal type BPPV.
Other resurfacing methods (Semont method for posterior semicircular canal BPPV, several other methods for horizontal semicircular canal BPPV) are addressed in this recommended specification. These recommended specifications are based on the generalization of data from many randomized trials in recent years.
Conclusions and recommendations
BPPV is highly suggested when the patient describes vertigo and nystagmus as being induced by a change in head position and not accompanied by other signs or symptoms; if the patient’s vertigo is induced by head movements, the DixCHallpike maneuver should be considered first (Figure 1).
Transient vertigo with upward rotational nystagmus is suggestive of posterior semicircular canal BPPV. for the treatment of posterior semicircular canal BPPV, we recommend the Spley repositioning method and the Semont repositioning method, which can be repeated several times if one time does not work. We expect that 80% of patients will be cured with the first repositioning method, but patients should understand that BPPV is prone to recurrence and will need to be treated again after recurrence.