Benign Paroxysmal Positional Vertigo (BPPV) Expert Interview
Interview: Chen Xiowu, Chief Physician, Department of Otolaryngology, Head and Neck Surgery, Beijing Tongren Hospital
Interview Topic: Recurrent vertigo may be caused by otoliths
What is otolithiasis? What are the symptoms of otolithiasis?
Dr. Chen Xiuwu: Hello, my name is Chen Xiuwu from the Department of Otolaryngology, Head and Neck Surgery, Beijing Tongren Hospital. I am mainly engaged in the clinical diagnosis and treatment of inner ear diseases such as deafness, tinnitus and vertigo.
Today we will talk about otoliths. First of all, what is the difference between dizziness and vertigo?
Dr. Xiuwu Chen: Dizziness and vertigo are two completely different concepts that can be easily confused. Patients with dizziness only have a feeling of dullness and swelling of the head and a feeling of lightness and discomfort, while patients with vertigo feel a sense of mutual incongruity and rotation between themselves and peripheral objects.
Is otolithiasis often referred to as vertigo? What is otolithiasis?
Dr. Xiuwu Chen: Otolithosis is a very typical form of vertigo. It is called benign paroxysmal positional vertigo, or BPPV, and it is a kind of postural induced vertigo, which can be triggered when the patient is in a particular position. For example, getting up in the morning, lying down to sleep at night or suddenly turning over to one side while sleeping, or tilting one’s head down or tilting one’s head up to dry one’s clothes may cause vertigo.
What are the symptoms of otolithiasis?
Dr. Chen Xiuwu: This kind of vertigo usually occurs in a fixed position or head position, and can be relieved by changing the position or head position immediately; but when the position that triggered the vertigo is repeated again, the symptoms may appear again, so it is also called positional vertigo.
In other words, vertigo in otoliths can recur?
Dr. Chen Xiuwu: Yes, vertigo can recur. But the triggering factor must be related to the body position.
Can otolithiasis heal itself?
Dr. Chen Xiuwu: Benign paroxysmal positional vertigo, so-called benign means that this disease can be cured by itself, most people will disappear within two weeks to one month after the onset of vertigo, and this vertigo is in bursts, not continuous.
This disease is very typical of vertigo, but there are also many clinical diseases related to vertigo, such as sudden deafness, Meniere’s disease, etc. How to distinguish these diseases from otoliths?
Dr. Chen Xiuwu: All of these diseases you mentioned earlier can cause vertigo, but the difference is that the vertigo caused by these diseases is not related to the change of body position.
What is the cause of otolaryngitis?
Dr. Xiuwu Chen: The inner ear includes three main parts: the cochlea, the vestibule, and the semicircular canal. The cochlea is responsible for hearing, and the snail-like structure in the inner ear is the cochlea, which is responsible for sensing sound. The balance of the ear is maintained by the vestibular system. The slightly enlarged part of the cochlea is called the vestibule, and it contains two particularly important parts, an ellipsoidal sac and a bulbous sac, both of which have a bite-sensitive spot that can sense changes in position. Under the microscope, we can see some tiny calcium carbonate crystals on the surface of the locus coeruleus, which is what we call “otolith”. Behind the vestibule, there are three hemispheres: the superior (anterior) hemispheres, the horizontal hemispheres, and the posterior hemispheres. The anterior part of the semicircular canal is enlarged and contains the cilia of the sensory cells that feel the balance, and the semicircular canal is connected to the vestibule by five holes.
Under normal circumstances, otoliths are also metabolically shed, and these shed otoliths are not problematic if they are engulfed by the relevant cells. Under abnormal conditions, such as aging and degeneration, inadequate local blood supply, and other diseases, otoliths may also be shed.
If not engulfed, the dislodged otoliths will fall down the canal into the semicircular canal, which has the greatest chance of falling into the posterior semicircular canal because of its posterior location. After the otolith is dislodged, otolithiasis is formed.
Why does otolithiasis cause vertigo? Why does vertigo often occur after lying down?
Because the semicircular canal is filled with endolymphatic fluid, and after the otolith is dislodged, it will flow with the lymphatic fluid, and since its specific gravity exceeds that of the lymphatic fluid, the otolith will fall into the semicircular canal after lying down. The stimulation of the semicircular canal will produce abnormal signals, which will be transmitted to the cerebral cortex through the vestibular nerve reflex, thus producing a vertigo response. Patients with otolithiasis may not only feel vertigo, but may also experience nystagmus.
What kind of people are prone to otoliths?
What kind of people are prone to otoliths?
Dr. Xiuwu Chen: Otolithiasis is related to old age and weakness, and degeneration of the ear stones. In some people, otoliths are dislodged due to poor circulation in the inner ear; in others, otoliths are dislodged due to trauma, excessive exercise, head impact, etc. There are also conditions such as inflammation and local embolism of the vestibular vessels, which can also lead to otolith dislodgement.
The main theories of otolithogenesis are the semicircular canal theory and the jugular crest otolith deposition theory. However, it is not particularly clear what exactly causes otolith dislodgement.
Case 1: Otoliths due to trauma
As an example, a 70-year-old woman suddenly fell during her morning walk, injuring her head and face. After that day, every morning when she got up and every night when she went to bed, she felt dizzy and uncomfortable as long as she turned to the right side, but turned to the left side and she was fine. I did an otolith provocation test on her, and the test results confirmed that it was otolithiasis of the right posterior hemimelia, so I reset her otolith, and the vertigo symptoms disappeared after only one reset. After a year of follow-up, she had no otolith attacks and was doing quite well.
Is this a secondary type of otolith, caused by trauma?
Dr. Chen Xiuwu: Yes.
Case 2: Otoliths caused by excessive exercise
Another type of otolithiasis is caused by excessive exercise. For example, if you already have poor blood supply to the inner ear and poor blood circulation, if you do some strenuous exercise, it can easily cause otoliths. I met a young girl who was particularly obsessed with yoga and often over-practiced, shaking her hair back and forth dozens of times a day. Soon after, she felt vertigo and dizzy very badly, every time she got up, lay down to sleep or turned over. She was later diagnosed with otolithiasis and was given a reset and got better. However, she relapsed a few months later because she started to practice shaking her head every day again, and the vigorous shaking of her head caused the otoliths to fall out. I specifically advised her not to do any more strenuous exercises for at least three months or even six months after the reset.
Are these strenuous exercises mainly for the head?
Dr. Chen Xiuwu: Yes, it’s mainly for the head, but not for the body.
The risk of otoliths increases with age, can children get otoliths?
Dr. Chen Xiuwu: The chance of otoliths occurring in children is not very high. There was a 6-year-old boy who was not clearly diagnosed after many tests in the hospital. This child felt particularly uncomfortable and painful as soon as he lay down, so he did not want to sleep. He was given a position elicitation test and it was determined that it was a right posterior hemianopsia. A subsequent reset was done and the child was well and never had another episode.
Another young boy, who had just started first grade, came in for a week with vertigo and was in particular pain. The child joined the martial arts team and had to do 50 forward rolls every day, but within a week the child felt uncomfortable with vertigo and could not lie down to sleep. After an examination, it was determined that the problem was otoliths, and after a reset, the child immediately recovered. When he returned, he continued to participate in the martial arts team, still doing 50 forward rolls every day, and within a week the otoliths came out again.
Vertigo in children can sometimes be related to excessive exercise, for example, some children move too quickly, and when combined with poor circulation in the inner ear, it can easily cause the otoliths to fall out. If otoliths are found to be caused by excessive exercise, it is important to avoid such exercise for at least a month after otolith repositioning, and to pay attention to gentle exercise, which is more beneficial to the child’s recovery.
What tests are needed when otoliths are suspected?
What should I do when a patient has vertigo?
Dr. Xiuwu Chen: When you have vertigo, you should come to the hospital to see if it is positional vertigo.
Which department should I go to?
Dr. Chen Xiuwu: In the past, many patients did not know which department they should go to for this disease, some went to neurology, some went to orthopedics, some went to internal medicine, but none of them were good. We recommend to try to see the otolaryngology department first.
If otolithiasis is suspected, what tests do I need to do to confirm the diagnosis?
Dr. Chen Xiuwu: The most critical test for otolithiasis is the positional evocation test. There are two main types of positional evocation tests, one is the varus nystagmus evocation test and the other is the tumble test.
The first test: the variable nystagmus evocation test
Have the patient sit on the examination bed with the eyes facing forward, turn the head 45 degrees to the right, and quickly lie on his back, paying attention to keep the head to the right at all times and protecting the neck; at this time, the patient’s head is tilted back 20 degrees, showing an angle of 20 degrees with the horizontal plane. In the case of otoliths, the patient will feel dizzy and the eyes will sway back and forth when looking at things. This back and forth swaying of the eyes is called nystagmus and lasts for about 30 seconds, or longer for some patients and shorter for others. Observe until the dizziness disappears, then have the patient sit up quickly. In case of otolaryngitis, the patient will feel that the direction of looking at things has changed, which is completely different from what he/she felt just now, as he/she felt that he/she was turning counterclockwise, but after sitting up, it is exactly the opposite. We wait until this symptom is completely gone and the nystagmus is gone, and then do the following steps. Let the patient turn 45 degrees to the left side, then lie down again and observe whether he/she is dizzy or not; if he/she is dizzy, the doctor should observe the patient’s nystagmus; if he/she is not dizzy, sit up after a pause of 10-20 seconds. After sitting up, let the patient rest for about 30 seconds, and then we repeat the test just now. During the process, we should compare with the previous test to see if his dizziness and nystagmus have been reduced. If the dizziness and nystagmus are reduced, it is consistent with the characteristics of vertical hemianopsia, which is a diagnostic criterion to distinguish it from central positional nystagmus.
Second test: Tumbling test
Let the patient lie flat on the examination bed, and turn the body and head together. Some patients with cervical spondylosis simply twisting their heads may induce some uncomfortable sensations in the neck, so we advocate rolling the whole body and head in a cylinder shape; first turn to the right, and if dizziness occurs, nystagmus will appear, and the direction of nystagmus is usually downward (groundward) or upward (off-ground); observe until the nystagmus disappears and then lie flat, face up on the back, and likewise Observe the performance just now, and then do a cylinder roll to the left side after the check, turn the head 90 degrees, observe that the nystagmus is not dizzy and comes down, and then continue to lie on your back, and this check is finished. To put it simply, if you turn to the right side and lie flat, and then turn to the left side and lie flat again, the rolling check will be completed.
Will the anti-dizziness medication I took before the test interfere with the test results?
Dr. Chen Xiuwu: If you take sedatives, there will be some interference, but it doesn’t matter much. You can take a little bit of medicine for general examination. However, it is better not to take any medicine if you are having a nystagmography test.
If otolithiasis is diagnosed, reset treatment is preferred
If otolithiasis is diagnosed, how should it be treated?
Dr. Chen Xiuwu: The most important treatment for otoliths is manual repositioning, which is a very good treatment method.
How many types of manipulation are there? How do they work?
Dr. Chen Xiuwu: There are two types of manual repositioning methods most commonly used in clinical practice, one is called Epley’s method, which is mainly for otoliths in the posterior and anterior hallucinations of the vertical hallucinations, and the other is called Barbecue’s tumbling method, which is mainly for otoliths in the horizontal hallucinations. There are many other repositioning methods, so I won’t go over them all here today, but first I will talk about the two most basic repositioning methods.
The first reset method: Epley’s method
If the right posterior otolith has been confirmed during the previous examination, the right side can be directly reset. Have the patient sit on the examination bed, turn the patient 45 degrees to the right, and then have the patient lie down, at which time the patient will feel very dizzy and observe until his vertigo and nystagmus symptoms disappear. Next, we asked the patient to turn his head to the median position and observe until the nystagmus disappeared, and then turn 45 degrees to the left side to observe if the symptoms still existed. At the same time, we asked the patient to turn his body to the left, into a left lateral recumbent position, and observed that the nystagmus symptoms disappeared, and then asked the patient to turn 90 degrees downward, presenting a 45-degree angle with the horizontal floor. Just now, the patient was first turned 45 degrees from the median position to the left side, and now he was turned 90 degrees again, and the overall turn was 135 degrees, presenting a 45-degree angle with the ground. After the repositioning is completed, if the dizziness is gone and no nystagmus is seen, the patient can be prepared to sit up. Before sitting up, both legs are stretched to the left side of the bed, and then the head position is maintained to return to the sitting position, and then the head is returned to the neutral position with the chest and head lowered by 20 degrees.
The second reset method: Barbecue tumbling reset method
Now we will talk about the second method of restoration for horizontal hemimelia – Barbecue tumbling restoration method. If the patient is found to have a right-sided horizontal otolith, let him turn to the right side to induce vertigo and nystagmus, and when the symptoms disappear, let him lie flat on his back and observe if he still has vertigo and nystagmus. When these symptoms disappear, the patient is asked to turn his entire body 90 degrees to the left. When the patient’s vertigo and nystagmus are gone, let the patient turn 90 degrees downward and become a prone position; when all symptoms disappear, do the next action, continue to turn 90 degrees to the left, which is the third 90 degrees. The reset is completed.
Will the patient feel the vertigo disappear immediately after the restoration?
Dr. Chen Xiuwu: Yes, if the repositioning is successful, the vertigo will disappear immediately. Of course, some patients may have a feeling of stuffiness and swelling in the head or unsteadiness in walking within 24 to 48 hours. This is because the otolith is not comfortable when it returns home (vestibule) after wandering from the semicircular canal or other places.
If the patient does not feel vertigo, it means the otolith has been cured?
Dr. Chen Xiuwu: Yes, that should be the case.
Which people are not suitable for manual repositioning?
Dr. Chen Xiuwu: If the patient has high blood pressure, poor heart function, or has a precursor of cerebrovascular disease (such as embolism or bleeding) or retinal detachment, glaucoma, etc., they are not suitable for otolith repositioning. Because the head has to be tilted back and droop during the resetting process, these conditions are prone to accidents. Therefore, patients with this type of otoliths should first go to the relevant department for examination or treatment, and then undergo otolith resetting treatment after these diseases are better controlled. During this period, patients can first take some medications to relieve their symptoms, such as anti-vertigo medications and medications to improve inner ear circulation.
What should I do if I have recurrent otoliths after resetting?
Why do some patients have recurrent vertigo after the reset?
Dr. Chen Xiuwu: There are several cases after the reset. The first case is that the reset may not be successful and the otolith is not in place, so of course vertigo will occur. In the second case, some tiny otoliths may still be wandering in the semicircular canal, and vertigo may also occur, but the patient may feel that the symptoms are reduced. In another case, if the operator is not experienced enough, the otolith may leave the original semicircular canal and wander into another semicircular canal during the reset, and if an examination is done, it will be found that the patient’s nystagmus direction has changed, and the reset will have to be done again in this case. In another case, the otolith is successfully reset, and it is hard to drive the otolith to where it should go (ellipsoidal sac), but after some time, the otolith is dislodged again in a certain position, and the patient will have vertigo again after the recurrence.
When the otolith recurs, can the patient get help from relatives at home to do the reset based on the web video?
Dr. Chen Xiuwu: I suggest that it is better to go to a hospital. Although it is not too difficult to reset the otolith, it still needs a doctor with a strong professionalism to do it. As I mentioned earlier, there are many conditions that may lead to unsuccessful reset. Without experience, it is difficult to determine which side of the otolith is involved, and some otoliths will have vertigo when turned left or right, so you must have a lot of professional experience to make an accurate judgment. The left otolith and the right otolith turn in completely different directions and have different effects, so it is recommended to do the reset in the hospital.
What items should be checked if the otolith has recurred?
Dr. Chen Xiuwu: If the otolith recurs, it is best to go to the hospital for further examination. You should go to the hospital to see an experienced otolaryngologist for a second look, because some small errors can cause the reset to be unsuccessful. When you arrive at the hospital, the doctor will ask about the patient’s medical history and find out if the position that caused the vertigo is the same as before. If it is determined that the otolith is recurring, the patient will need to be repositioned again.
If the patient has other symptoms, such as high blood pressure, dizziness instead of positional vertigo, and just feels drowsy and uncomfortable, not like the sky is spinning, it may not be otoliths. In this case, it is possible that the vestibular function is weakened. Such patients may have tinnitus or other uncomfortable sensations, so an audiogram, nystagmogram, head shake test or vestibular evoked potential test should be done to see if the problem is a peripheral vestibular nerve or a central one.
What should I do if I still don’t see any improvement after repeated resetting?
Dr. Chen Xiuwu: Then you need to do a detailed examination, such as vestibular function examination, to see if there are any accompanying problems. Some patients with sudden deafness with otolithiasis or vestibular neuronitis have reduced vestibular function and are prone to vertigo. The vertigo of otoliths is completely different from this vertigo. The vertigo of otoliths is characterized by a transient positional vertigo induced by a fixed position.
Have you encountered any cases of this kind of vertigo that do not get better after repeated resetting in the clinic?
Dr. Chen Xiuwu: We also encounter patients with recurrent attacks of recalcitrant otolithiasis. In this case, special repositioning methods can be used. There is a common angle between the superior and posterior hallux, and this common angle leads to the vestibule. When the otolith is dislodged, it usually comes out of the common angle and enters the semicircular canal, where it returns to the oval sac of the vestibule during the repositioning process. The expanded part of each semicircular canal is called the potbelly, which contains the ridge of the potbelly. The surface of the ridge of the potbelly has some sticky collagen, so if the otolith sticks to the ridge of the potbelly, normal rotation cannot make it fall off. In this case, special movements (such as gently tapping the mastoid area behind the patient’s ear during repositioning) are needed to make the otoliths fall off the potbelly ridge. Then, the patient can determine the location of the otolith according to the direction of the patient’s nystagmus, and then do the corresponding repositioning treatment according to this location, which will be more effective. If the otolith is still stuck to the jugular ridge, other more complex methods of otolith repositioning are required.
How can I prevent recurrence of otoliths?
Do recurrent attacks affect my body and will it damage my hearing?
Dr. Chen Xiuwu: Patients who have recurrent attacks do not feel free from the pain, but still feel dizzy and uncomfortable. Some patients feel dizzy when they sleep, and some are even afraid to sleep, which is very painful and seriously affects their quality of life. However, otoliths should not have much effect on hearing, and usually otoliths are not accompanied by tinnitus and deafness.
Will otoliths become more and more frequent after multiple recurrences?
Dr. Chen Xiu Wu: This is not necessarily true. The frequency of attacks varies from person to person, and each person is different.
What do I need to pay attention to in order to prevent recurrence?
Dr. Chen Xiuwu: Generally, after the reset, the doctor will advise the patient not to turn over to the right side if the otolith is on the right side. When you sleep, you can add a pillow and try to lie on your back or turn to the left side. Do not move too much when lying down and getting up. You will be fine after 24~48 hours.
What should I pay attention to in my daily life?
Dr. Chen Xiuwu: We should pay attention to our daily life, at least for a month, don’t do particularly strenuous exercise, and don’t ride in a car or motorcycle too bumpy. You can do some exercises such as slow walking, brisk walking, and tai chi. In the process of resetting otoliths, I have found that many patients lie down or get up with extra large and fast movements, which makes them prone to recurrence after resetting.
The incidence of otoliths increases with age, and the average age is about 42 years old. It is recommended that older patients move more slowly when lying down or getting up, hold their hands a little and move as smoothly as possible to reduce recurrence. There are reports that otoliths may be related to poor blood supply to the inner ear, and there are also claims that it is related to calcium deficiency and osteoporosis. Therefore, it is important to pay attention to the prevention and treatment of cardiovascular diseases, such as atherosclerosis and triglycerides, to control fat and cholesterol in the diet, and to pay attention to general life care, diet and living, which are also beneficial to prevent the recurrence of otoliths.
Please recommend some safe and effective rehabilitation health exercises.
Dr. Chen Xiuwu: There are several rehabilitation exercises commonly used in clinical practice, and the most common one is called the vestibular rehabilitation exercise, or the Brandt-Daroff rehabilitation exercise. This exercise requires patients to do three times a day, each time to do six sets, the effect is quite good. The specific practice is this: first let the patient sit on the examination bed, home sofa, bedside can also be, two feet natural down; the whole body first to the right side of the rapid side, a second or two later, some patients will feel dizzy; wait until not dizzy, about ten seconds, head turned upward 45 degrees; and then wait until not dizzy, upright sit up; next according to the steps just now, to the left and repeat once, a set of actions is complete The set of movements is completed. This kind of vestibular rehabilitation is especially suitable for patients who are not able to determine whether they have otolithiasis on the left or the right side, and it is good for their recovery. In some cases, the otoliths are more complex, such as those stuck to the jugular ridge, and can be easily repositioned by doing this regularly.