BENIGN PAROXYSMAL POSITIONING VERTIGO
Benign paroxysmal positioning vertigo (BPPV) is a common cause of recurrent vertigo. BPPV is characterized by the onset of transient vertigo lasting 15 to 60 seconds associated with movement of the head. Associated symptoms include nausea and less commonly vomiting. Symptoms of vertigo lessen with repetition of the provocative head positioning. Common provocative factors include rolling over in bed, bending over, looking upward, or turning the head to a certain side. The sensation caused by movement of free floating calcified particles within the semicircular canal is responsible for the feeling of vertigo. There may be a history of antecedant head trauma, and if there is such a history, an ENT consultation may be required to rule out the possibility of a perilymph fistula.
The Dix-Hallpike test is used to establish the diagnosis. The Dix-Hallpike maneuver is performed by starting with the patient in the sitting position. The examiner stands to one side and rotates the patients head in that direction. The patient is instructed to keep their eyes open throughout the exam, and the examiner then supports the patient’s body weight while reclining the patient into the supine position with the head extended over the edge of the examining table. The onset of nystagmus or symptoms of vertigo are considered positive and the diagnosis is confirmed. The patient is then returned to the seated position and again observed for symptoms of vertigo. The test is then performed on the contralateral side and in the neutral position (head straight forward).
Once the diagnosis is established, the Epley maneuver may prove therapeutic. The Epley maneuver is performed by first having the patient in the supine position with their neck extended over the edge of the table and their head rotated 45 degrees to the side with the positive Dix-Hallpike test (further instructions are given based on a positive Dix-Hallpike test on the right). Once the symptoms of nystagmus cease, the head is rapidly rotated to the left with the face towards the left shoulder and the right ear is pointing upwards. This position is maintained for 30 seconds and then the patient is instructed to roll towards the left into the left lateral decubitus position while the examiner rotates the head to the left until the face is towards the floor. This position is maintained for 30 seconds and then the patient is rapidly lifted into the sitting position (if the Dix-Hallpike test had been positive on the left, the test would be reversed with the patient ending sitting on the right side of the examination table). More than one treatment session may be required. The Epley maneuver may also be performed with additional stimulation by a hand-held vibrator or manual massage. Symptoms are often recurrent and may be treated by repeating the Epley maneuver. Meclizine is ineffective for treating BPPV.