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maculae[1] of the inner ear into the fluid-filled semicircular canals. These semicircular canals are sensitive to gravity and changes in head position can be a trigger for BPPV[2]. The
posterior canal is the most commonly affected site, but the superior and horizontal canals can be affected as well[3]. It should be noted that the superior canal is sometimes also referred to as the anterior canal and the horizontal canal is sometimes referred to as lateral canal. The peripheral vestibular labyrinth contains sensory
receptors in the form of ciliated hairs in the three semicircular canals and in the ear’s otolithic organs. They respond to movement and relay signals via the eighth cranial nerve. Visual perception such as gravity, position, and movements also receive signals from somatosensory receptors in the peripheral vestibules. With the displacement of the otoconia into the semicircular canals, these delicate feedback loops relay conflicting signals that can result in any symptom related to
BPPV[4]. BPPV can be classified as cupulolithiasis and canalithiasis. Cupulolithiasis is when the otoconia are adhered to the cupula, whilst canalithiasis is when the otoconia are free floating in the canal. Additionally, the type of nystagmus that a patient may display can be classified as geotropic or apogeotropic.
Geotropic describes the nystagmus as a horizontal beat towards the ground. Apogeotropic describes the nystagmus as a horizontal beat towards the ceiling[5]. [6] Clinically Relevant Anatomy[edit | edit source]Interior View of Labyrinth Benign paroxysmal positional vertigo (BPPV) is a specific type of vertigo that is brought on by a change in position of the head with respect to gravity. This disorder is caused by problems in the inner ear. Its symptoms are repeated episodes of positional vertigo, that is, of a spinning sensation caused by changes in the position of the head.[7] The vestibular system monitors the motion and position of the head in space by detecting angular and linear acceleration. The 3 semicircular canals in the inner ear detect angular acceleration and are positioned at near right angles to each other. Each canal is filled with endolymph and has a swelling at the base termed the ampulla. The ampulla contains the cupula, a gelatinous mass with the same density as endolymph, which in turn is attached to polarized hair cells. Movement of the cupula by endolymph can cause either a stimulatory or an inhibitory response, depending on the direction of motion and the particular semicircular canal[8]. There is a vestibular apparatus within each ear so under normal circumstances, the signals being sent from each vestibular system to the brain should match, confirming that the head is indeed rotating to the right, for example. Within the labyrinth of the inner ear lie collections of calcium crystals known as otoconia. In patients with BPPV, the otoconia are dislodged from their usual position within the utricle and they migrate over time into one of the semicircular canals (the posterior canal is most commonly affected due to its anatomical position)[8]. When the head is reoriented relative to gravity, the gravity-dependent movement of the heavier otoconial debris (colloquially ear rocks or crystals) within the affected semicircular canal causes abnormal (pathological) fluid endolymph displacement in the affected ear. This fluid displacement will send a signal to the brain indicating that rotational movement is occuring. However, the vestibular apparatus in the unaffected ear will not be transmitting the same signal because there are no loose otoconia triggering the hair cells abnormally. This resultant mismatch in signals coming from the right and left vestibular systems lead to the sensation of vertigo. This more common condition is known as canalithiasis. Vertigo associated with this condition will be of short duration, even if the person with the condition stays in the provocative position, because the endolymph and otoconia will quickly come to a rest so the hair cells will no longer be displaced and triggering the signal to the brain. In rare cases, the crystals themselves can adhere to a semicircular canal cupula rendering it heavier than the surrounding endolymph. Upon reorientation of the head relative to gravity, the cupula is weighted down by the dense particles thereby inducing an immediate and maintained excitation of semicircular canal afferent nerves. This condition is termed cupulolithiasis. Vertigo associated with this condition will not resolve until the head is moved out of the provocative position because even when the endolymph comes to a rest, the adhered otoconia will continue to displace the hair cells and trigger the signal of movement to the brain. It can be triggered by any action which stimulates the posterior semi-circular canal which may be:
BPPV may be made worse by any number of modifiers which may vary between individuals:
Etiology/Causes[edit | edit source]The most common cause of BPPV is idiopathic. However, the vestibular system of the inner ear can also undergo degenerative changes as one ages which can attribute to a potential cause of BPPV. Under age 50, head injury is a common cause. Vestibular viruses and Meniere’s
disease also play a role. BPPV can also be a result of surgery due to prolonged supine positioning and possible trauma to the inner ear[9]. Risk factors include[2][10][11]:
Prevalence [edit | edit source]
Clinical Presentation[edit | edit source]The signs and symptoms of BPPV are often transient, with symptoms commonly lasting less than one minute (paroxysmal).[15] Episodes of BPPV can resolve after a few weeks or months, but may reappear at a later time. Signs and symptoms may include:[15]
Research suggests there is a definite correlation between cognitive skills and balance in women patients affected with chronic peripheral vestibulopathy[17].
Associated Co-morbidities[edit | edit source]There are conditions that appear to more prevalent in patients that experience BPPV, for example:[2][5]
Differential Diagnosis[edit | edit source]Otological disorders include:[12]
Other possible causes are:[12]
Neurological disorders include:[12]
Contraindications[edit | edit source]Physical therapy is not appropriate for unstable vestibular disorders such as
Diagnostic Procedures[edit | edit source]BPPV can easily be diagnosed and treated through simple clinic-based procedures.[18] In the past, a wide variety of different tests and procedures have been explored for diagnosis of BPPV, but many of these techniques have been discredited in recent years. Currently the primary method of diagnosis involves in-depth subjective screening, followed by physical investigations and diagnostic manoeuvres to confirm BPPV. These methods of diagnosis have been shown to be clinically appropriate, simple to perform, and cost effective.[7] Early diagnosis of BPPV is important and may help improve quality of life for patients and reduce the risk of more serious injury. Techniques may be easily incorporated into routine physiotherapy assessment and should be considered for any patients presenting with symptoms of dizziness and vertigo. The condition is diagnosed from patient history (feeling of vertigo with sudden changes in positions) and by performing a positional test. Different positional test exist. The exact positional test used to confirm the presence of BPPV will depend on which semicircular canal is involved. Subjective Assessment[edit | edit source]The subjective assessment is the first step in clinically diagnosing BPPV. Any complaints of dizziness necessitate the taking of a detailed patient history and further investigation of the symptoms.[19] Patient history alone is insufficient to accurately diagnose BPPV, but patient description of vertigo can give a very good indication of the cause.[7] Clinicians should look out for patients describing sudden severe attacks of vertigo or dizziness, precipitated by head position and movement.[20] The most common movements thought to provoke symptoms are rolling over in bed, extension of the neck to look up, and bending forward.[20] Patients typically describe their vertigo as a rotational or spinning sensation provoked by these movements.[7] Different studies have aimed to identify and validate useful questions when suspecting a diagnosis of BPPV. There are however no current guidelines for appropriate BPPV screening questions. Some important aspects of the condition have been identified which should be explored to rule out other causes[16]. Clinicians should be asking patients questions regarding: 1. Type of dizziness and vertigo Physical Assessment[edit | edit source]If details of the subjective assessment and patient history indicate BPPV, then further physical investigation is needed to confirm a diagnosis. Physical diagnosis maneuvers involve a series of movements which aim to provoke nystagmus and symptoms of vertigo. The two diagnostic maneuvers used clinically are the Dix-Hallpike maneuver and the Supine Roll Test. A positive result on either of these tests indicates a diagnosis of BPPV. They also help to distinguish the type of BPPV and identify the ear involved. Dix Hall Pike[edit | edit source]The most commonly used test is Dix-Hallpike which assesses involvement of the posterior canal (the most commonly affected semicircular canal).[21] The test involves turning the head 45 degrees to the side being tested and then quickly moving from a seated to a supine position with the head declined 30 degrees below the trunk. The test must be performed quickly to ensure sufficient displacement of the endolymp and otoconia to provoke the expected symptoms. The test is considered positive for canalithiasis of the posterior canal if vertigo is provoked and nystagmus is observed, both of which should be of short-duration for canalithiasis. The direction of the observed nystagmus should be consistent with the canal being assessed. For the posterior canal, nystagmus should be up-beating and torsional in an ipsilateral direction (if testing the affected side. If the left side is affected but the test is performed with the head turned to the right, the nystagmus would be up-beating and torsional to the right). Horizontal Roll Test[edit | edit source]This test is to assess the horizontal semicircular canal
Head Pitch Test (“Bow and Lean” Test)[edit | edit source]This test is used to assess unilateral horizontal canal BPPV[14]
The nystagmus associated with BPPV has several important characteristics which differentiate it from other types of nystagmus.
If nystagmus and vertigo are sustained, cupulolithiasis or a potentially more central cause of vertigo should be considered. Patient history and other neurological tests can help to rule out a more serious central cause. Physiotherapy Management[edit | edit source]Research review implies that the posterior and horizontal canal BPPV canalith repositioning maneuvers (Semont, Epley, and Gufoni's maneuvers) are level 1 evidence treatment, and the choice of maneuver (since their efficacy is comparable) is up to the clinician's preferences, failure of the previous maneuver, or movement restrictions of the patient.[24] Two treatments have been found effective for relieving symptoms of posterior canal BPPV:
Epley Maneuver[edit | edit source]
Semont Maneuver[edit | edit source]
Lempert Maneuver[edit | edit source]Treatment for horizontal/lateral canal BPPV
Gufoni Maneuver[edit | edit source]Treatment for horizontal/lateral canal BPPV
Habituation Techniques[9][edit | edit source]
Vestibular Rehabilitation Exercises[edit | edit source]Vestibular rehabilitation exercises are commonly included in the treatment of BPPV and are designed to train the brain to use alternative visual and proprioceptive cues to maintain balance and gait.[29] It has been shown that these exercises improved nystagmus, postural control, movement-provoked dizziness, the ability to perform activities of daily living independently, and levels of distress.[29] While no single vestibular rehabilitation exercise has been shown to reduce the symptoms of BPPV, a program of therapies that can include self-administered repositioning maneuvers, gaze stabilization exercises, falls prevention training, and patient education may be beneficial in reducing the symptoms of BPPV and improve quality of life.[30] The evidence supporting the efficacy of vestibular rehabilitation exercises in reducing symptoms of BPPV is lacking.[30] Steenerson et al.[31], found that Epley’s maneuver administered by a health care practitioner was a better treatment technique than vestibular rehabilitation exercises. Vestibular exercises were, however deemed to be better than no treatment at all. No single form of vestibular rehabilitation exercise has been found to be superior and exercises appear to have a greater effect when performed together, rather than as single exercises alone.[30] Cawthorne-Cooksey Exercises[edit | edit source]The Cawthorne-Cooksey exercises aim to relax the neck and shoulder muscles, train eyes to move independently of the head, and to practice balance and head movements that cause dizziness.[32] The exercises consist of a series of eye, head, and body movements, in increasing difficulty, which aim to provoke symptoms.[30] The goal of these exercises is to fatigue the vestibular response and force the central nervous system to compensate by habituation to the stimulus.[30] A video description of the Cawthorne-Cooksey Exercises[edit | edit source][33] Brandt-Daroff Exercises[edit | edit source]The Brandt-Daroff exercises are a series of particle repositioning exercises that can be performed without a qualified health professional present and are easily taught to the patient.[32] While beneficial, these exercises are more time consuming than other forms of treatment. They are completed by the patient in bed, 3 sets a day for 2 weeks and aim to help reduce the chance of reoccurrence of BPPV and promote the loosening of canaliths.[30] Radke et al.[34] found that when these exercises are performed as the only form of treatment, they were successful at relieving the symptoms of BPPV in only 25% of individuals after one week of administration. The Brandt-Daroff exercises have been found to be a beneficial adjunct treatment in the symptomatic relief of BPPV.[30] The Brandt-Daroff exercises may be summarized in the following steps (see Figure 7): Figure 7. The Brandt-Daroff Exercises
A video demonstration of the Brandt-Daroff Exercises[edit | edit source][35] Medical Management[edit | edit source]BPPV is a benign diagnosis so treatment is not always needed. Occasionally, BPPV can resolve itself with no intervention[36]. Surgery[36]:
Medications:
Outcome Measures[edit | edit source]There are many outcome measures used when treating patients with vertigo, such as:[37][39]
Resources[edit | edit source]
References[edit | edit source]
Which anatomical area of the ear contributes to benign paroxysmal positional vertigo?BPPV is a mechanical problem in the inner ear. It occurs when some of the calcium carbonate crystals (otoconia) that are normally embedded in gel in the utricle become dislodged and migrate into one or more of the 3 fluid-filled semicircular canals, where they are not supposed to be.
Which auditory disorders are related to the inner ear?Sensorineural deafness is a type of hearing loss. It occurs from damage to the inner ear, the nerve that runs from the ear to the brain (auditory nerve), or the brain.
Which portion of the middle ear equalizes pressure?The Eustachian tube, which opens into the middle ear, is responsible for equalizing the pressure between the air outside the ear and that within the middle ear.
Which nerve is present in inner ear?Coming from the inner ear and running to the brain is the eighth cranial nerve, the auditory nerve. This nerve carries both balance and hearing information to the brain.
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