POSITIONAL VERTIGO (BENIGN PAROXYSMAL POSITIONAL VERTIGO)

Benign paroxysmal positional vertigo is a sensation of spinning related to head movement and position. The spinning sensation or vertigo only lasts for brief periods and is not associated with ear fullness or tinnitus. The vertigo experienced can be quite intense and patient may have nausea.
It may occur repeatedly with certain head positions such as tilting the head backwards and forwards, looking to the sides and turning to right or left on the bed. In between episodes, patients are generally well.
BPPV is one of the most common cause of vertigo and it commonly affects those above 50 years of age. Occasionally it can be related to head trauma especially in young adults.

Understanding the disease process of BPPV
BPPV is a condition affecting the inner ear. Each inner ear consists of organs responsible for hearing (cochlea) and balance (utricle, saccule & 3 semicircular canals). The balance organs especially the semicircular canals are responsible to detect angular head movements.
When the head moves, the fluid within the semicircular canal would move in the opposite direction initially due to inertia. This fluid movement is detected by the cupula which contains hair like sensors. These sensors would then produce electrical signals to the brain.
In BPPV there is dislodgement of crystals from the utricle or saccule which then collects within the semicircular canals. Therefore during head movements, these crystals would cause the semicircular canals to send false signals to the brain. And this brain signal misinterpretation would cause the patient to feel the spinning sensation of vertigo.

Diagnosis of BPPV
The diagnosis of BPPV is a clinical diagnosis which the doctor makes from the patient's history and examination. A complete ENT examination should be performed to assess for other causes of vertigo. In BPPV, the ear examination is generally normal.
Sometimes a hearing assessment is also required. If the symptoms are non specific, imaging studies such as MRI (magnetic resonance imaging) may be performed to assess for any intracranial cause.
The doctor would also perform a Dix Hallpike manouvre to stimulate a vertigo episode. This test would be positive in cases of BPPV.

Treatment of BPPV
A canalith repositioning manouvre for BPPV can be performed by the doctor in the clinic. The side of the ear affected will be determined during the Dix Hallpike manouvre. And then the canalith repositioning manouvre will be performed according to the affected ear; right or left.
The canalith repositioning manouvre, also called the Epley's manouvre, involves a series of head movements aimed at bringing the crystals out from the semicircular canals and back into the utricle. This test may need to be repeated several times. It is usually performed twice and may be repeated during the next clinic review if still symptomatic.
In very rare situations that the canalith repositioning manouvre would fail and surgery is recommended. The surgical procedure performed involves plugging the semicircular canal that causes the vertigo.

Home advice after repositioning manouvre
There is no substantial clinical evidence that has shown that the following restrictions are very useful after the clinic canalith repositioning procedure. However doctors often advise patients to avoid lying flat or on the affected ear for 2-3 days after the procedure. Patients are also advised to lay their head on 2-3 pillows on the first night following the procedure.

VERTIGO- I FEEL THE EARTH MOVE UNDER MY FEET

Vertigo refers to a symptom of spinning sensation; either patient feel themselves spinning or the room spinning around them. It is a very distressing symptom associated with nausea and vomiting.

It is foolhardy to determine the cause of vertigo with this short article. However there a few clues that the doctors will elicit from a patient with vertigo:

• How long does the vertigo lasts; seconds, minutes or hours?
• Is there sensation of ear fullness/block or tinnitus?
• Does a certain head position bring on the vertigo, such as looking left or right?
• Do you experience nausea or vomiting?
• Have you been feeling unwell or had fever in the last 2 weeks?
• Is there any ear discharge or ear pain?
• Did you bump your head or fell?
• Do you experience any weakness or numbness in other parts of your body?
• Did you faint or lose consciousness?
• Do you have any history of migraine, diabetes or hypertension?

What are the causes of vertigo?

There is an exhaustive list of possible causes of vertigo. Therefore it takes proper consultation and examination before the doctor can provide a possible cause and treat accordingly.

• Benign paroxysmal positional vertigo- The most common cause of vertigo. Patients experience a short duration of vertigo related to certain head positions. The doctor can reproduce this vertigo during Dix-Hallpike examination and confirm the diagnosis. The treatment is simply a manouvre that is done in the clinic which gives immediate relief. Sometimes the manouvre needs to be repeated for complete resolution.

• Meniere’s disease-Patient’s have vertigo lasting minutes to hours associated with tinnitus and reduced hearing. Often there is nausea and vomiting too.  In between episodes, patients are symptoms free.

• Vestibular neuronitis- It is a condition due to inflammation of the vestibular nerve.  It is hypothesized to be due to viral infection. Patients have vertigo symptoms with nausea and vomiting. There is no hearing loss or tinnitus.

• Labyrinthitis- This is another condition due to inflammation of the inner ear or labyrinth. Patients have vertigo with hearing loss and tinnitus. The hearing loss can be severe and permanent if not treated early. It is due to viral or bacterial infection.

• Middle ear disease such as otitis media or cholesteatoma. Cholesteatoma is a non tumour condition resulting in whitish debris seen within the middle ear. Treatment of cholesteatoma often require surgery.

• Cerebellar stroke or hemorrhage leading to disruption of oxygen supply and blood flow to the base of the brain area (cerebellum) which is an important central portion that controls balance.

• Head trauma can cause vertigo or dizziness which is often temporary.

• Vertebrobasilar insufficiency is related to cervical spine problems. This can lead to occlusion of blood supply to the inner ear especially when patient looks up or down.

Other causes of vertigo which are less common: Ototoxicity, Cerebellopontine angle tumour, Migraine

Treatment of vertigo

The treatment recommended for the patient will depend on the diagnosis. And recovery from the vertigo will also depend on the diagnosis and patient factors such as age and other co-morbidities.

The choice of treatment can be a combination of the following:

Medication- Betahistine is commonly used for vertigo. Other medications are also used during the acute attack of vertigo such as prochloperazine and metoclopramide. In the case of bacterial infections in labyrinthitis, antibiotics are prescribed as well.

Vestibular rehabilitation exercises which are a series of movements that can help patients regain their balance. Other similar exercises recommended include tai-chi.

Particle repositioning manouvres which is a manouvre that is performed in the doctor’s office for benign paroxysmal positional vertigo such as the Epley’s manouvre. There are other types of manouvres that can be performed depending on the semicircular canal involved.

Lifestyle advice which includes avoiding alcohol, reducing stress, low salt diet for Meniere’s disease, reducing caffeine intake, good adequate sleep and rest