Benign Positional Dizziness

Benign Paroxysmal Positional Vertigo (BPPV) is characterized by dizziness and nystagmus (rapid involuntary eye movements) that occur with certain head positions. It is a condition that typically shows spontaneous improvement over time.

The cause of the disease is the dislodgement of small calcium crystals (canaliths) located in the inner ear, which normally remain attached in the region that detects gravity. When these crystals become free within the inner ear fluid and enter the balance canals that have opened up, typical symptoms are triggered after certain head movements (canalithiasis). The shape and direction of the detected nystagmus vary depending on the affected balance canal, but usually, the posterior balance canal is involved. Involvement of the horizontal and superior/anterior canals is observed very rarely.

Before the mechanism of BPPV formation was fully understood, various treatment methods were used in patients diagnosed with this pathology. Due to the lack of proven effective pharmacological treatments, it was also noted that avoiding head movements that trigger attacks is the most effective treatment method. Additionally, various surgical techniques have been defined for BPPV cases that do not respond to other treatments and are severe enough to affect patients’ lives.

Since the disease is self-limiting and can be largely controlled by repositioning canaliths using the canalith repositioning maneuver (CRM), CRM is the preferred first treatment option.

DIAGNOSIS

The diagnosis of BPPV is made according to the following criteria:

• The patient’s history includes a sensation of dizziness triggered by head movements and changes in body position,
• During the Dix-Hallpike test, where the patient’s head is turned to one side and then quickly lowered backward while keeping it slightly extended, a nystagmus resembling a wheel’s rotation (rotatory nystagmus) is observed towards the lower ear after a 2-5 second waiting period, along with the development of dizziness and/or nausea,
• The nystagmus is short-lived (fatiguing nystagmus is usually less than 20 seconds),
• When returning to an upright position, a nystagmus in the opposite direction and of shorter duration occurs,
• The history, examination, and when necessary, hearing, balance tests, and radiological evaluations exclude pathologies of the brain, brainstem, vestibular nerve, and cerebellum.

TREATMENT:

In a very large portion of patients diagnosed with BPPV due to canalithiasis of the posterior balance canal, symptoms are resolved using the canalith repositioning maneuver (CRM = Epley and Hallpike maneuvers).

After CRM, patients are advised not to lie on the affected ear side for 48 hours, to sleep on their backs or the opposite side with a high pillow, to avoid bending forward, not to lift their heads upwards, and to refrain from sudden movements. Patients are called back for a control within 2 to 5 days. If nystagmus and/or dizziness is detected during the control Dix-Hallpike test, CRM is repeated. Patients in whom the problem is not detected are discharged from follow-up with instructions to return if symptoms recur.

The rate of complete symptom resolution with a single treatment is around 75-90%. With 2-3 treatments, complete recovery or a significant reduction in symptoms can be achieved in 84 to 100% of cases.

Although the exact cause of BPPV cannot be identified in most patients, the main identifiable causes in some patients include head trauma or concussions, advanced age, circulation disorders, periods of prolonged bed rest, and other ear diseases.

High success rates demonstrate that CRM is not only a painless and easy method but also a highly effective treatment tool. Considering the low rate of accompanying pathologies and the successful results achieved with CRM, it is accepted that standard diagnostic methods to differentiate other causes of dizziness are not necessary in patients diagnosed with BPPV based on history and CRM. This approach provides economical treatment while avoiding unnecessary and sometimes discomforting advanced diagnostic methods.