Benign paroxysmal positional vertigo (BPPV) is a mechanical problem of the peripheral vestibular system resulting from otoconia being displaced into the semicircular canals. It is the most common cause of recurrent and episodic vertigo from a peripheral vestibular disorder. In the general population, BPPV has an incidence of 64 new cases per 100,000 people per year. With such a high incidence in the general population, an understanding of the disease and its proper management becomes imperative. Treatment of posterior semicircular canal BPPV has been studied extensively, and there is considerable research that supports “best practice” for its assessment and management. We first describe the proposed mechanisms for BPPV and then explore the assessments and various treatment alternatives for this disorder.
Characteristics and History
BPPV is characterized by brief episodes of vertigo, with the perception of either the environment or one's self spinning when the head is moved into certain positions. It has been reported in adults of all ages, although it is relatively uncommon in children.1,2 Although BPPV can occur spontaneously in many patients, it has been known to follow head trauma, labyrinthitis, or ischemia in the distribution of the anterior vestibular artery.1 Spontaneous remission of this condition is common. For those patients in whom the episodic vertigo persists, this disorder can be annoying, disruptive, and often results in significant changes in normal activities.
Patients with BPPV commonly report vertigo triggered by lying down, rolling over in bed, bending over, and looking up. Common situations in which vertigo is provoked include getting out of bed, gardening, washing hair in the shower, and going to the dentist or beauty parlor. Other complaints associated with BPPV include balance problems that may last for hours or days after the episodic vertigo has stopped and more vague sensations such as lightheadedness or a feeling of floating (Table 20-1).
Table 20-1FREQUENCY OF COMPLAINTS IN 100 CONSECUTIVE PATIENTS WITH BPPV |Favorite Table|Download (.pdf) Table 20-1 FREQUENCY OF COMPLAINTS IN 100 CONSECUTIVE PATIENTS WITH BPPV
|Complaints ||Frequency (%) |
|Poor balance ||57 |
|Sense of rotation (vertigo) ||53 |
|Trouble walking ||48 |
|Lightheaded ||42 |
|Nausea ||35 |
|Queasy ||29 |
|Spinning inside head ||29 |
|Sense of tilt ||24 |
|Sweating ||22 |
|Sense of floating ||22 |
|Blurred vision ||15 |
|Jumping vision ||13 |
Historical Mention of BPPV-like Vertigo
Adler first described the clinical presentation of BPPV in 1897 in his paper on “unilateral vertigo” and recognized that the posterior and anterior semicircular canals (SCC) were most likely the affected structures.3 He reported, “Active or passive movements of the head toward the diseased side … elicit severe vertigo, which can be so intense that patients become pale, diaphoretic, and ...