The main symptom of BPPV is intense, brief vertigo, which may occur along with nausea and vomiting. The key feature of BPPC is that the vertigo follows a change in head position.  The symptoms often first occur in bed, with a sudden turn or getting up. Other patients will experience vertigo by looking up. Clinically, the patient will develop vertigo and rotatory nystagmus when moved from a sitting to head-hanging position (provocative test for BPPV). ENG testing for simultaneous horizontal and vertical eye movement is important to document the affected ear and peripheral vestibular nerve function.

A number of causes are identified including head or ear injury, motor vehicle accidents, infections, mastoiditis, association with Meniere’s disease, acoustic neuroma and other surgery (e.g., stapedectomy), anesthetic agents, toxic fumes, and degeneration of the vestibular system; however BPPV may be idiopathic. Mechanism is felt to be due to basophilic deposits that land on the cupula of the posterior canal of the affected ear. These deposits represent otoconia released from a degenerating utricular macula . 

Antivertiginous medications (e.g., meclizine 25 mg q6h, betahistine 8mg,  or Phenergan^R 25 mg q8h) may be used initially to decrease dizziness and control nausea and vomiting. Ear etiologies such as Meniere’s disease and  tumors should be identified and treated. General ear care including a well balanced diet, decreasing sodium, alcohol, and caffeine intake will be necessary modifications. Smoking is a factor which may increase symptoms.

Exercise regimens include Epley positioning maneuvers and Brandt positional exercises. These exercises may increase symptoms and patients need to be forewarned prior to initiation. Although this physical therapy is uncomfortable for a short period, improvement is usually more rapid. The Epley maneuvers involve positioning the head in the supine position to move the debris in the canal of the affected semicircular canal into an area where no symptoms will be elicited when the head is turned. This speed up recovery and in many cases will "cure" the condition. Patients are asked to sleep in a sitting up position/ in a recliner for the first 2 nights following the office procedure. Normally, BPPV resolves over a three-month period. Recurrences occur in approximately 20% of cases over a long period of observation.

In persistent BPPV and recurrent cases in which incapacitating symptoms persist (> 6 months) with observable nystagmus, an ear canal plugging surgical procedure is recommended. This involves an ear operation as an outpatient. This procedure results in relief of positional vertigo. Normally, patients are allowed to go home following the procedure and return to the office for further care and examinations on the second post- op day. Questions -= lease contact me thru email at wleliever@aol.com 

William C. LeLiever MD FACS FRCS ( C )

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