Benign Paroxysmal Positional Vertigo

Introduction: Benign Paroxysmal Positional Vertigo (BPPV) is a common type of dizziness caused by debris that has collected in the semicircular canals of the inner ear and that interferes with their normal function. This disorder increases in incidence with age, but may be seen in persons of any age.  In persons over the age of 50, about half of all dizziness symptoms are attributable to BPPV. In general, about 20% of dizziness is caused by BPPV and 9% of all older persons have BPPV.

Symptoms: The symptoms of BPPV include vertigo, light-headedness, disorientation, disequilibrium, imbalance and nausea. The most characteristic symptom of BPPV is a violent spinning which lasts for only 5 to 15 seconds. Activities which bring on symptoms will vary in each person but always involve movement or position changes of the head or body. A patient may be sensitive to certain position changes for days, weeks, or months. The strength of the symptoms tends to diminish before they disappear. Approximately 30% of patients experience recurrences of BPPV symptoms. The most characteristic provocative motions include rolling over in bed and tipping the head back to back to look up. Typical histories include severe bursts of vertigo which begin while using a hair dryer, when having hair washed in a beauty parlor, removing items from a top kitchen shelf or when looking up to change a ceiling-mounted light bulb. More constant non-episodic symptoms, such as chronic lightheadedness or disequilibrium are also common, especially in individuals who carefully avoid all provocative movements and positions.

Causes: BPPV is caused by a displacement of tiny calcium carbonate crystals called otoconia (ear stones) from the utricle (a balance organ in the inner ear) into the semicircular canals, where they remain trapped and interfere with the normal function of the balance canals. After otoconia are loosened, they are normally absorbed by special cells (dark cells) around the utricle where they arise. If too many otoconia fall off at once, they may find their way into the semicircular canals before they can be absorbed. This typically occurs while the patient is lying down. The trapped particles continue to move within the semicircular canals after the head changes position, and cause the canals to send the brain inaccurate signals that the head is still moving. The result is bursts of severe vertigo brought on by changes in head position. 

For BPPV to occur, otoconia have to be displaced from the utricle into the semicircular canals. More otoconia tend to fall off of the utricle as we age and off of a utricle which has been injured by a virus or migraine. BPPV is 3 times more common among patients with migraine. Otoconia are commonly shaken from the utricles in head trauma and even in high-impact fitness activities. The most common form of BPPV comes from debris trapped in the posterior semicircular canal. This is the form illustrated above and in the animation below. Approximately 5% of patients may also have symptoms of BPPV from debris trapped in the horizontal semicircular canal. Even fewer patients have debris trapped in the superior semicircular canal. Most commonly, the horizontal or superior canals are affected in addition to the posterior canal.   Because BPPV is more likely to occur in a sick ear which may be causing symptoms of dizziness, the straightforward positioning symptoms of BPPV may not be easily recognized. Similarly, BPPV may continue to recur if the underlying trauma (e.g. migraine, high-impact exercise) is not recognized and treated or prevented. In cases with atypical findings and in which multiple balance system pathologies co-exist, a full diagnostic work up may be required in order to distinguish pathologies which will require different forms of therapy. 

To see an animation of BPPV, go to http://www.dbi.udel.edu/MichaelTeixidoMD/flashmovies/bppv.swf.

Diagnosis: The diagnosis of BPPV is relatively straight-forward due to the characteristic history and rotary vertigo which can be induced using the Hallpike maneuver. In this maneuver, the patient sits up on the exam table, turns the head 45˚ to one side, and lies down flat. It is repeated on each side. If a significant number of displaced crystals are present in the semicircular canals on the side to which the head is turned, vertigo will be provoked. The symptoms typically begin a few seconds after the lying down position is reached and last for about 5-15 seconds. The physician can determine the canal or canals involved by analyzing the eye movements provoked. Vertigo can also be provoked after the patient arises from the lying down position.

Treatment: BPPV usually goes away by itself within six months of onset because of changes which occur both within the semicircular canals and in the brain. These processes cannot take place if the central nervous system has lost its ability to adapt to chronic abnormal stimulations, if the patient carefully avoids positions which provoke the vertigo, or if the ear continues to be injured by processes such as aging, migraine, or trauma. Such patients may have symptoms for years before presenting to the clinic.  Vestibular suppressant medications are rarely effective because the characteristic symptoms are so violent and brief.   The treatment of this common vestibular disorder involves head movements designed to either 1) displace the otoconia from the affected semicircular canal(s) back into portion of the inner ear where there is an active mechanism for their resorption or 2) move the otoconia back and forth within the canal to promote their dissolution. Physical maneuvers to displace otoconia from the affected semicircular canal differ according to the canal affected. .  The canalith repositioning procedure (CRP) is a series of head maneuvers which displaces debris collected within the posterior semicircular canal out of the canal back into the utricle where they can cause few symptoms. This maneuver is successful in approximately 85% to 90% of cases and is usually performed in the office by a clinician with special expertise in balance disorders. To be effective, the clinician must correctly determine which ear is affected. Patients who choose to have this done must be willing to sleep semi-recumbent or vertically the night after the maneuver is performed. In patients with chronic, recurrent BPPV, the canalith repositioning procedure can safely be done at home, following specific instructions given by their clinician. As seen in the figures below, the CRP sequence differs for left and right posterior canal BPPV. We have found that the performance of a single daily CRP before arising from bed in the morning is an effective and efficient way to prevent symptoms in patients with chronic recurrent BPPV. In some severe cases, we have had success teaching patients to perform a home CRP for the right and left ears on alternating days.

 

 

Upper airway resistance syndrome

Upper Airway Resistance Syndrome (UARS):  is a sleep condition characterized by airway resistance to breathing during sleep.  The symptoms of upper airway resistance syndrome are daytime sleepiness and excessive fatigue; patients with UARS usually snore a lot and may be awakened from sleep by resistance in the airway. Unlike a person with sleep apnea, a person with UARS does not have periods when breathing stops (apnea), and there is no decrease in the person's airflow. UARS is characterized by muscles of the airway during sleep become relaxed and partially collapse of the airway resulting in increased resistance to airflow.  Due to the reduction of these muscles, airways become narrowed. The airway of the person suffering from upper airway resistance syndrome restricts and reduced in size and this relaxation reduces the airway further. Therefore breathing becomes difficult. The increased respiratory effort required results in multiple sleep fragmentations as measured by very short alpha EEG arousals.  The resistance to airflow is typically subtle and does not result in apneic or hypopneic events.  However, it does result in increasingly negative intrathoracic pressure during inspiration, which can be measured using an esophageal manometer as an adjunct to polysomnogram. Increased upper airway resistance in this syndrome does not lead to cessation of airflow or decrease in airflow, but instead leads to an arousal secondary to increased work of breathing to overcome the resistance. There is no decrease of oxygen but with measurement of airflow through the nose and mouth, there are signs of decreased breathing. Arousals and sleep fragmentation resulting with arousals are related to increased effort to breathe. It is detectable with measurement of pressure changes in the esophagus. The esophageal pressure starts to decrease just before the arousal which indicates increased effort to maintain the flow of air which is only slightly reduced.

Due to the repeated arousals of the patient, which he is usually unaware of, results in an abnormal sleep and daytime sleepiness. Due to multiple arousals, upper airway resistance syndrome causes hypertension similar to obstructive sleep apnea.

Restless legs syndrome

Restless legs syndrome is a condition caused by uncomfortable sensations in the legs that produce an intense, often irresistible urge to move the legs. This can lead to sleep disturbance and severe fatigue that interferes with daily activities.

These sensations are described as "pins and needles," prickling, creeping, crawling, tingling, and sometimes painful. They most often occur in the evening when the person is attempting to relax or sleep. Moving the legs can temporarily relieve these sensations.

The cause of this syndrome is often not known. Certain drugs (such as antidepressants), pregnancy, or iron deficiency or related anemia can trigger it.

Restless legs syndrome can be treated with drugs such as those that increase the brain chemical dopamine (levodopa or dopamine agonists), pain medications (opioids), or anticonvulsants (gabapentin) to control leg movements and assist with sleep.

Hearing Loss

Sensorineural Hearing Loss

Sensorineural (or “nerve” hearing loss) results from damage to the hair cells, nerve fibers or both in the inner ear. This is the most common type of hearing loss and is often caused by aging or prolonged exposure to noise. People with sensorineural hearing loss can hear speech, but frequently have difficulty understanding it. Sensorineural hearing loss is most commonly treated by the use of a hearing instrument, and generally cannot be corrected through surgery or medicine.

Conductive Hearing Loss

Conductive hearing loss typically involves an obstruction in the outer or middle ear, which reduces transmission of sound vibration through air, bone or tissue to the inner ear. Conductive hearing losses can be treated successfully by medical or surgical procedures. Hearing instruments can also successfully treat conductive hearing loss. Persons with both conductive and sensorineural hearing loss are commonly referred to as having mixed hearing loss.

Eustachian Tube Dysfunction

The Eustachian tube connects the middle ear to the throat. Its purpose is to equalize middle ear pressure with environmental pressure. When your ear “pops” on a high-speed elevator or in an airplane, the reason is that the Eustachian tube has opened and equalized pressure. Occasionally people develop symptoms when the Eustachian tube does not equalize pressure. In other words, it is closed when it should be open. This may involve pain or fullness. Fullness in the ears can be a very troublesome symptom that can also arise from TMJ (jaw joint) disturbances, migraine, and Meniere’s disease.