Benign paroxysmal positional vertigo: causes and treatment of BPPV, ICD-10 code, exercises and gymnastics

What is BPPV and how to distinguish it?

According to ICD-10, benign paroxysmal positional vertigo is coded H81.1. The disease is characterized by paroxysmal dizziness, which occurs due to displacement of the otoliths and is accompanied by additional symptoms. The disease is treatable, but after several years the manifestations may recur. It received its name based on the general characteristics of the pathology:

• benign – does not cause complications, can be treated independently;
• paroxysmal – manifested by attacks;
• positional – occurs due to a change in position;
• dizziness is the main symptom.

Dizziness in a person can occur for many reasons, so one symptom does not give a clear picture of the pathology; BPPV can be distinguished only by a combination of symptoms.

How does the vestibular apparatus work?

Before talking about the causes of paroxysmal positional vertigo, it is necessary to consider how it occurs.

The organ in the inner ear, the vestibule, is based on three semicircular canals. Their function is to record human movements. The channels contain an ampoule and a certain amount of liquid. The ampoule is an extension that houses a gelatin-like substrate, the cupula. Her movements, interacting with receptors, help create a sense of balance in her body.

The liquid in the ampoule contains calcareous formations called otoliths. When a person performs any actions with his head, the liquid also begins to move. As a result, the otoliths are displaced, which irritate the nerve endings (ciliated cells).

All information about a change in position is transmitted by ciliated cells to the nerve endings of the brain. Due to failures and problems at this stage, a person develops benign paroxysmal vertigo. The part of the brain responsible for balance gives a signal to the muscles, thanks to which they relax or, conversely, become toned. These processes are aimed at maintaining balance in space. When the otoliths settle, the dizziness stops.

Essence and basic principles

The Epley maneuver or exercises are a special maneuver used to treat benign paroxysmal positional vertigo (BPPV).

This procedure is often carried out in a physiotherapy office, but it can also be done at home after a specialist shows all the basics of the technique. This maneuver was developed by Dr. John Epley, after whom it was named. The first time it was talked about was back in the 80s of the last century.

The Epley maneuver is a series of exercises that help relieve symptoms of dizziness. Numerous studies have proven that this technique is the simplest, safest and most effective in the treatment of dizziness caused by the deposition of calcium salts in the inner canal of the ear.

All these exercises do not eliminate the presence of otoliths, but only change their location. Such manipulations cause them to move to other areas of the inner ear that do not cause dizziness.

The essence of the technique is to place your head at an angle at which gravity helps relieve unpleasant symptoms. Tilt of the head helps remove crystals from the semicircular ear canals. This means that they stop displacing fluid, which is what causes nausea and dizziness in a person.

As a result, it turns out that this maneuver relieves all symptoms, but you need to do the set of exercises several times. The thing is that the first time the crystals can move a small distance.

There are a number of rules that must be followed:

• classes should take place in a well-lit room;
• there should not be any objects with sharp corners, carpet paths, or objects that could cause a person to fall near the patient;
• It is better to perform the exercise on a soft surface; a couch, yoga mat, or thick-pile carpet are suitable for this;
• the clothes a person wears should be loose, not restricting movements, so that he can move easily and freely;
• shoes on feet should be without heels;
• while performing exercises, someone must be present next to the person; it is unknown how his body will react to the exercise; someone needs to provide backup;
• if a person feels unwell or has symptoms of other diseases, then therapy is postponed until the person feels better;
• Even after the Epley maneuver is successfully performed, when the results sought are obtained, you will need to visit the doctor several more times to prevent a relapse.

Experts who recommend the Epley maneuver to their patients for symptoms such as dizziness note that after the first use of a set of exercises, serious changes are observed. The symptoms go away, but only if you follow all the prescribed recommendations for several days after them.

Treatment of BPPV

Various therapeutic positional maneuvers are used to treat BPPV. The choice of the necessary manipulation depends on the affected semicircular canal and some characteristics of the patient. The therapeutic maneuver, like the diagnostic one, is carried out on the couch, and sometimes immediately after the last one. The essence of this procedure is that the doctor sequentially changes the position of the patient's head and body so that the otoliths move along the semicircular canal and eventually return back to the vestibule. If the required positional maneuver is performed correctly, its effectiveness is very high - about 60-80% of cases can be stopped at the first visit. In more complex cases, the doctor may recommend additional independent exercises at home until the next consultation. In this case, as a rule, no medications are required - only occasionally symptomatic treatment may be needed to reduce the intensity of manifestations, for example, to combat severe nausea or vomiting.

After recovery from BPPV, there are no consequences, which is why the disease is called benign. However, relapses often occur - somewhere in 40-50% of cases. Since the exact cause of otolith “loss” in most cases is still not known, we cannot prevent the recurrence of this disease - there are no reliably working means of preventing relapse. Therefore, the doctor usually does not recommend changing your lifestyle after recovery. In some cases, it may be necessary to rule out vitamin D deficiency. If a relapse does occur, there is no need to panic - you should contact a specialist as soon as possible to carry out positional maneuvers.

Classification and stages of development of benign paroxysmal positional vertigo

According to the pathophysiological mechanism, BPPV can be divided into two types:

• Canalithiasis - when the otoconia are located inside the semicircular canal. When moving, they cause dizziness.
• Cupulolithiasis - when otolith crystals are attached to the cupula, creating additional pressure on the receptors. When turning, they cause an attack.

Depending on the location of the lesion and the location of otoconia in the vestibular apparatus, the following variants of the disease are distinguished [17]:

• Canalolithiasis of the posterior canal is the most common type of lesion. Mainly affects the right side of the labyrinth of the vestibular apparatus. Accompanied by repeated attacks of dizziness within a minute, which occur in a lying position or when turning the body on the back.
• Canalolithiasis of the horizontal canal - occurs when otoconia enters the horizontal canals. It is checked by turning the head like a “barbecue”, that is, in a circle. Occurs when the head turns sharply or when the body moves from side to side.
• Cupulolithiasis of the horizontal semicircular canal is caused by otoconia crystals falling on the cupula of the canal. Pseudospontaneous nystagmus is noted, which is not associated with a change in head position.
• Probable BPPV, spontaneously resolved - when the dizziness resolved before coming to the doctor, but based on the patient's story it is possible to diagnose BPPV. During diagnosis, nystagmus and positional vertigo do not occur.

Rare variants of BPPV (they can be confused with central positional vertigo):

• Canalolithiasis of the anterior canal is much less common than other types of dizziness. It can be diagnosed only after excluding diseases of the central nervous system.
• Cupulolithiasis of the posterior semicircular canal is detected quite rarely. Dizziness may occur when a person bends their head forward to tie their shoes or wash their hair. The attack itself lasts less than a minute, but if the person has not changed the provocative position of the head, then the time of the attack increases. The same symptom is observed with cupulolithiasis of the horizontal canal.
• Lithiasis in multiple canals is a very complex variant of the disease, affecting up to 20% of patients with BPPV. May be a complication of therapeutic maneuvers. Sometimes requires hospital treatment.
• Possible BPPV is more likely a concomitant condition. It is noted when other causes of positional vertigo have been excluded, and the described attacks do not meet the criteria for BPPV.

The type of BPPV depends on how it is treated.

The form of positional vertigo is distinguished depending on the location of the grains of calcium bicarbonate salt:

1. Canapolitiasis. Localization of grains in the canal cavity.
2. Cupulolithiasis. The cupula of the vestibular canal is susceptible to formations.

The disease is also characterized by severity and location, as it affects the anterior, posterior or semicircular canal.

Classification of BPPV

When classifying pathology, specialists take into account the area of ​​damage to the vestibular apparatus, as well as the mechanism of development of the pathological process and other features. That is why there are several groups of the disease.

The type of pathology is determined during a diagnostic examination.

Contraindications for use

The Epley maneuver is prescribed by a doctor only after examination, examination and an accurate diagnosis. It is also worth remembering that these exercises can only be recommended for stable, non-progressive illness.

Among these pathologies:

• period after a stroke;
• benign positional paroxysmal vertigo;
• violation of movement coordination;
• osteochondrosis;

  

• recovery period after injury to the spine or brain;
• ear diseases;
• infectious pathologies.

Gymnastics does not affect muscle function in any way. Its main goal is to teach a person to control attention, so regular use does not cause any unwanted manifestations.

The Epley maneuver for dizziness is a safe therapeutic procedure, but it does have a number of contraindications.

It is prohibited to carry out manipulations if the patient:

• with active manifestations of symptoms: confusion, disorientation;
• respiratory function is impaired if there are problems with the functioning of the heart, blood vessels, and respiratory organs;
• worsening after exercise.

In other cases, the maneuver can be carried out, but it is better to do this under the supervision of a specialist.

Disease prevention

There are no specific measures to prevent benign positional vertigo, but there are some recommendations that a person can follow to avoid the disorder:

1. Try to avoid situations in which there is a risk of injury, as well as use protective equipment and follow safety precautions when engaging in dangerous sports.
2. Treat infectious diseases in a timely manner: otitis, sinusitis, meningitis, etc.
3. If possible, replace other antibiotics from the aminoglycoside group, after consulting with your doctor.
4. Promptly treat circulatory disorders in the vessels of the head.
5. Get at least 8 hours of sleep a day and avoid stressful situations.

Since BPP can cause inflammation, it is therefore important to lead a healthy lifestyle, take vitamins and strengthen the immune system. If the disease already exists, then specially designed exercises described above are a good treatment and prevention of attacks.

Preventive measures for benign positional paroxysmal vertigo have not been developed to date since the etiological factors in the development of the disease have not been fully elucidated.

As a recommendation, patients should not drive a car for some time.

The pathological condition may persist for several days or weeks after treatment. As for the restoration of ability to work, it can also be difficult for several weeks, but one should take into account the fact that benign positional vertigo can recur over time and when such a moment occurs is not known.

Classification and stages of development of benign paroxysmal positional vertigo

The true causes of benign paroxysmal positional vertigo cannot always be determined; there are suggestions that people have a hereditary predisposition or acquire a defect in the inner ear. There may be several factors causing disturbances in the functioning of the vestibular apparatus. They may be related to:

• head injuries;
• infections in the inner ear;
• Meniere's disease;

  

• operations on the inner ear;
• the effect of antibacterial drugs;
• by compressing the arteries located in the semicircular canals.

The cause of the condition is not always established; there may be cases when PPG turns out to be a symptom of other pathologies.

Causes and mechanism of development of BPPV

To understand why and how this disease develops, it is necessary to delve a little deeper into the structure of the vestibular apparatus.

The main part of the vestibular apparatus is three semicircular canals and two sacs. The semicircular canals are located almost at right angles to each other, which makes it possible to record human movements in all planes. The channels are filled with liquid and have an extension - an ampulla. The ampoule contains a gelatin-like substance, cupula, which has a close connection with the receptors. The movements of the cupula, together with the flow of fluid inside the semicircular canals, create a sense of position in space in a person. The upper layer of the cupula may contain calcium bicarbonate crystals - otoliths. Normally, otoliths are formed throughout life and then destroyed during the natural aging of the body. Destruction products are utilized by special cells. This situation is normal.

Under certain conditions, spent and obsolete otoliths are not destroyed and float in the form of crystals in the fluid of the semicircular canals. The appearance of additional objects in the semicircular canals, naturally, does not go unnoticed. The crystals irritate the receptor apparatus (in addition to normal stimuli), resulting in a feeling of dizziness. When the crystals settle in an area under the influence of gravity (usually the area of ​​the sacs), the dizziness disappears. The described changes are the main mechanism for the occurrence of BPPV.

Under what conditions are otoliths not destroyed, but sent “free floating”? In half of the cases the cause remains unclear, the other half occurs when:

• traumatic brain injury (due to traumatic avulsion of otoliths);
• viral inflammation of the vestibular apparatus (viral labyrinthitis);
• Meniere's disease;
• surgical manipulations on the inner ear;
• taking ototoxic antibiotics of the gentamicin series, alcohol intoxication;
• spasm of the labyrinthine artery that supplies blood to the vestibular apparatus (for example, during migraine).

Main complex

Back in the early 80s of the last century, a set of exercises was developed, which today is called the Epley maneuver.

Its use allows calcium carbonate crystals to move out of the semicircular tubules under the influence of gravity. During this maneuver, the patient often experiences an increase in autonomic symptoms, which can be explained by the fact that otolith fragments are forced to move.

It is better to perform the maneuver for the first time only in the presence of a specialist. Its main feature is a clear trajectory, slow movement from one position to another, without any sudden movements.

The Epley maneuver for dizziness requires precise adherence to all exercise techniques:

1. The patient sits straight on the couch, turns his head towards the ear (45˚), in which an accumulation of otoliths is detected.
2. Without turning your head, you need to lie down on the couch with your head thrown back slightly. You need to stay in this position for at least 1 minute.

   

3. Turn your head 90˚ towards your healthy ear and hold for 30 seconds.

   

4. The body and head in a fixed position are turned in the same direction by another 90˚. The patient's face at this moment should be directed downward. Stops again for 30 seconds.
5. Again the person returns to the starting position, sitting on the couch.

While performing the maneuver, the person should feel slightly dizzy. If such a symptom appears, it means that he is doing everything correctly. All the exercises described above should be performed several times for 10 minutes. Only in this case can the full effect be achieved.

The Epley maneuver for dizziness does not accept any sudden movements; all manipulations must be smooth. After exercise, you should definitely rest. Regular exercise will allow you to gradually dissolve all the salts and forget about dizziness.

If after the first session of the Epley maneuver there are no results or the patient experiences frequent relapses, then in this case a modified procedure can be used at home. If you follow all the rules for doing the exercises, the symptoms disappear after a few days.

The Epley maneuver can also be used as a diagnostic tool in people who cannot be definitively diagnosed with BPPV but are strongly suspected to have it. But it is carried out only if the Hallpike tests are negative.

The main symptom of the pathology is dizziness, as evidenced by its name. It appears suddenly when a person changes body position. There is no clinic in a calm state. Basically, an attack occurs after abruptly getting out of bed, in particular when waking up in the morning, but it can happen when turning the head right in bed.

The patient feels as if he is falling through space, swaying on the waves, or objects begin to rotate. The duration of the attack rarely exceeds a minute, during which time the person experiences involuntary rapid eye movement (nystagmus). Less commonly, the condition accompanies:

• nausea and vomiting;
• increased sweating;
• pale skin;
• tachycardia.

Dizziness during the disease is always the same; there are no other neurological manifestations in the form of tinnitus, hearing impairment or headaches.

Clinic

Most patients experience a feeling of failure during a BPPV attack. It seems to him that objects around are moving in a circle or falling into emptiness.

In addition, there are other symptoms characteristic of this disease:

• An attack of dizziness lasts no more than 2 minutes, which allows you to endure it without taking medications.
• Headache is not typical for this disorder.
• Usually the patient talks about nausea, tinnitus, and increased activity of the sweat glands.
• Sometimes the attack is accompanied by vomiting, which does not depend on food intake and does not alleviate the patient’s condition.
• Almost always during an attack, the heart rhythm is disturbed, and the heart rate also increases.
• In most cases, the attack develops in the morning or afternoon. In this case, symptoms develop when turning the head, and not the entire body.

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Another feature of the pathology is short-term nystagmus, that is, involuntary twitching of the eyeball. Usually, after all manifestations disappear, the symptom also disappears. It is worth noting that the disease is highly treatable, but relapses can develop every 4-5 years, even if all recommendations are followed.

Useful tips for patients

There are some recommendations that will help you complete the procedure successfully with maximum results and without any inconvenience:

1. Before starting the exercises, the specialist recommends that the patient take a vestibulolytic drug. It will help reduce the severity of symptoms. Take dimenhydrinate in a dosage of 100 mg half an hour before the start of the procedure.

   
   Take 2 Dramamine tablets 30 minutes before the Epley maneuver for dizziness.

2. All exercises should be performed quickly, but without sudden movements.
3. When performing the maneuver, the neck should be extended as much as possible, thereby protecting against re-entry of calcium salts into the semicircular canal.
4. The patient may need to perform the maneuver several times in 1 session.

Folk remedies

To eliminate symptoms, infusions and decoctions of herbs that have sedative properties are used.

Chamomile infusion can be prepared from 3 g of dry herb and 300 ml of boiling water. After infusion for 20 minutes, the product is ready for use. It is worth taking 150 ml 2 times a day for 7 days.

A decoction of lemon balm and linden also helps eliminate dizziness and accompanying symptoms. For 500 ml of water you will need 5 g of each herb, cook for 3 minutes, leave for 40 minutes. Take 100 ml 3 times a day.

Mint infusion is the most popular remedy. You can get it from 3 g of dry leaves and 250 ml of boiling water. After infusion for 20 minutes, you can use the medicine. It's better to do this before bed. Repeat 7-10 days in a row.

Exercises

Special exercises for BPPV are recommended to be performed only after an accurate diagnosis, and some only in the presence of a doctor. The following manipulations will help relieve attacks of dizziness:

1. Brandt-Daroff method. To perform the exercise, a person sits in the middle of the bed with his legs down. Next, he lies on his side and turns his head up at an angle of 45 degrees. After lying down for 30 seconds, you need to sit down again and quickly lie down on the other side with your head turned at the same angle. After 30 seconds, sit down again. The exercise is performed 3 times a day, doing 5 bends in both directions.
2. Epley's maneuver. The patient sits along the couch and turns his head at an angle of 45 degrees to the side. Next, the person is placed on his back with his head thrown back in the direction of dizziness at the same degree. Then the patient is turned over on his side, the head should be turned down in the other direction. Afterwards, the person sits down and turns his head again in the direction of the manifestation of the symptom and returns to his original position. The movement is repeated 2 – 4 times.

   

3. Semont exercise. To perform this, a person sits in the middle of the bed with his limbs lowered and his head turned at an angle of 45 degrees to the healthy side. In this position they are laid on the opposite side. It is necessary to lie down until the dizziness stops completely. Next, the doctor helps you turn around on the other side, your head does not turn. The person sits down again after his condition has returned to normal.
4. Lempert's maneuver. The patient sits along the couch with his head turned to the painful side by 45 degrees. Next, the patient is placed on his back, turning his head in the other direction. Then the patient is helped to turn his stomach and head down, returned to his healthy side with his head turned to the painful side and sat down.

Regular use of specially designed exercises to prevent dizziness can significantly reduce their number and improve overall health. It is recommended to perform exercises every morning, since during their execution the osteolites move to the correct position.

The most effective methods are:

• Epley maneuver - during an attack, you need to move your head 45 degrees to the side in which the symptoms increase. Afterwards, you need to lie on the side on which the attacks do not occur or will decrease. To improve the condition, it is necessary to repeat the reception 2-4 times;
• Lempert's maneuver - after turning the head to the painful side and fixing it, you need to lie on your back and turn your head first to the healthy side, then again to the painful side and again to the healthy one. Apply daily in the morning;
• Brunt-Daroff method - lying on your side, turn your head 45 degrees up. Remain in this position for at least 30 seconds, then lower your head. Repeat the exercise another 5-10 times to consolidate the effect;
• Semont's maneuver - while sitting in the middle of the couch with your legs down, turn your head 45 degrees to the healthy side. It is necessary to fix this position and lie on your sore side with your head thrown back. This exercise will provoke the development of an attack, which will quickly stop. Doing it frequently will reduce the number of dizzinesses.

Vestibular exercises for BPPV

Diagnostics

The clinical features of BPPV make it possible to come close to the correct diagnosis already at the stage of questioning the patient. Clarification of the time of onset of dizziness, provoking factors, duration of attacks, absence of additional complaints - all this suggests BPPV. However, more reliable confirmation is needed. For this purpose, special tests are performed, the most common and simple of which is the Dix-Hallpike test. The test is carried out as follows.

The patient is seated on the couch. Then turn (do not tilt!) the head in one direction (presumably towards the affected ear) by 45°. The doctor seems to fix the head in this position and quickly places the patient on his back, maintaining the angle of rotation of the head. In this case, the patient’s torso should be positioned in such a way that the head hangs slightly over the edge of the couch (that is, the head should be thrown back slightly). The doctor observes the patient's eyes (anticipating nystagmus) and at the same time asks about the feeling of dizziness. In essence, the test is a provocative test for a typical attack of BPPV, since it causes displacement of crystals in the semicircular canals. In the case of BPPV, approximately 1-5 seconds after the patient is laid down, nystagmus and typical dizziness occur. The patient is then returned to a sitting position. Often, when returning to a sitting position, the patient again experiences a feeling of dizziness and nystagmus of less intensity and the opposite direction. This test is considered positive and confirms the diagnosis of BPPV. If the test is negative, then the test is performed with the head turned in the other direction.

In order to notice nystagmus during the test, it is recommended to use special Frenzel (or Blessing) glasses. These are glasses with a high degree of magnification, which eliminate the influence of arbitrary fixation of the patient's gaze. For the same purpose, a videonystagmograph or infrared recording of eye movements can be used.

It should be borne in mind that when the Dix-Hallpike test is repeated, the severity of dizziness and nystagmus will be less, that is, the symptoms seem to be exhausted.

Consequences

Benign vertigo has a favorable prognosis and is generally successfully treated without surgery. Cases of pathology progression with additional symptoms of vomiting are extremely rare.

Helpful information

The condition itself is not dangerous to health, but attacks that cause disorientation in space impose restrictions on some professions and hobbies. Systemic dizziness is dangerous when the patient is at heights, depths, when driving a car and performing other activities that require high concentration.

During periods of dizziness, a person may simply fall out of the blue and suffer serious injury, even death, which is why seeking medical help is extremely important for BPPV. Among other things, seeing a doctor is necessary, as dizziness may occur with other dangerous pathologies.

Warn and do no harm

The following measures can be taken to prevent the development of BPPV:

• prevention of damage to the balance organ by viral and other infectious agents;
• caution when performing work and other vital functions;
• careful attention to the use of medications;
• prevention of vascular disorders in the head and neck area.

The prognosis depends on the severity of concomitant pathology. The disease can become dangerous when the patient is at a significant altitude or depth with associated changes in atmospheric pressure, as well as in the event of a seizure developing in the operator of the mechanisms.

Consolidate the result

After exercise, you need to sit for 10 minutes. This is necessary to ensure that all the contents of the inner ear remain in place and do not move. This is the only way to protect yourself from repeated attacks of dizziness. You should wear a soft pillow around your neck for the rest of the day. With its help, you can limit head movements and record the results of the Epley maneuver for a long time.

In the days following the exercises, you need to sleep with your shoulders and head straightened. It is better to sleep in a position where your head is turned 45˚. During the day, after the Epley maneuver, the head should be kept upright. You should not visit a hairdresser or dentist at this time, who will ask you to tilt your head back.

After the Epley maneuver, you should wait a week and not provoke attacks of dizziness during this period. Check to see if symptoms appear if you take a position that previously caused them. If there is no recurrence of symptoms, then the procedure was successful.

Drug treatment

In order to alleviate the condition of a patient suffering from benign paroxysmal vertigo, medication treatment can be used. It will help get rid of nausea and other unpleasant symptoms. If attacks recur frequently, the patient must remain in bed.

The goal of treating such dizziness with medications is to improve the general condition of the patient. At the same time, medications may be prescribed that will help normalize blood circulation in the vessels of the brain.

In severe cases, surgery may be performed. It is used to fill the semicircular canal with bone chips. The surgical intervention method is used only in severe cases, as there is a risk of serious complications. There is no specific drug treatment for BPH.

Benign positional vertigo has a favorable prognosis for recovery. BPPV is a safe disease and does not pose a threat to human life.

What is BPPV syndrome?

Benign paroxysmal positional vertigo is diagnosed in 80% of patients with vertigo. It occurs in people of any age, but is more often detected in patients over 50 years of age. It is also often observed in pediatric practice in children of any age.

The occurrence of paroxysms is associated with a defect in the inner ear and vestibular apparatus. The development of symptoms is caused by the free floating of osteoliths, fragments of the otolithic membrane, in the endolymph of the vestibular apparatus.

During sudden movements of the head, they change their position and irritate the hair cells of the semicircular canal. The result is a short episode of dizziness.

According to ICD-10, diagnosis code: H81.1 – benign paroxysmal vertigo.

The diagnosis is not life-threatening for the patient. But due to disorientation in space, they often lose their balance and fall, which can result in quite serious injuries. Injury is especially important in elderly and elderly people who, due to an episode of BPPV, receive such serious injuries as fractures and cracks of bones, and head trauma. In rare cases, a fall can lead to disability or death.

Positional vertigo also significantly impairs quality of life. There is a fear of driving a car and other vehicles, many professions and sports become inaccessible. In rare cases, patients do not even leave the house for fear of falling and getting injured. Such fear, as a rule, is inherent in elderly and senile people who have previously received injuries due to dizziness.

Diagnosis of BPPV

Diagnosis of BPPV requires specific diagnostic positional maneuvers, the best known of which is the Dix-Hallpike maneuver. During the maneuver, the doctor changes the patient’s position so as to give the semicircular canal being examined the desired position and determine whether there is movement of the otoliths in it. When the semicircular canal is irritated by otoliths during a maneuver, in addition to the patient’s sensations listed above, a characteristic nystagmus reaction occurs - then the maneuver is considered positive.

Nystagmus is an involuntary rhythmic movement of both eyes that a person usually does not feel. Each semicircular canal is characterized by its own nystagmus, which helps the doctor determine in which canal the pathological process has developed. Diagnostic maneuvers are performed on a regular couch. The combination of the maneuver, the resulting nystagmus reaction and the patient's sensations allows us to confirm the diagnosis of BPPV. Moreover, in the vast majority of cases, there is no need for MRI of the brain or CT of the temporal bones - otoliths still cannot be seen in this way due to their size - neuroimaging methods may be needed in complex cases.

When to expect an effect

After the first session, within 3 days, and after a month, the patient is recommended to visit a specialist. If symptoms do not go away, you may need to repeat the maneuver or need to look for other causes and remedies to get rid of dizziness.

The Epley maneuver may not produce the desired results if:

• neck extension is insufficient, due to which calcium salts return to their place;
• the patient has blockage of the posterior semicircular canal with a conglomerate;
• the diagnosis was incorrectly made and the patient does not have canalolithiasis of the posterior semicircular canal, but cupulolithiasis, as a result of which, after performing the maneuver, the pressure goes in the opposite direction;
• transformation of BPPV of the posterior canal into BPPV of the anterior canal.

The table below shows other types of vestibular maneuvers that can be used if the Epley maneuver does not give the desired result. But they are used only on the recommendation of a doctor.

In rare cases, relapses may occur or the complex needs to be repeated, but after talking with the patient it turns out that he did not adhere to the recommendations. The maneuver is truly an excellent opportunity to remove otoliths from the inner ear, because they are the ones that cause an unpleasant symptom, but a favorable result is guaranteed only if all the rules are followed.

The Epley maneuver is an effective complex that helps a person get rid of dizziness without any harm to health.

Thanks to this technique, it is possible to normalize the vestibular apparatus if the problems are associated with the deposition of calcium salts in the inner ear. But it should only be carried out on the recommendation of a doctor, there is no self-medication and it is better to do everything the first time in the presence of a specialist.

Article design: Vladimir the Great

Non-drug treatment

For mild cases of the disease and rare attacks, non-drug methods are used to alleviate the patient’s condition.

This maneuver can be performed at home, since it does not provoke negative reactions. The patient should take a position sitting on a chair or ottoman with his legs hanging down.

The sequence of actions is as follows:

1. Take a position lying on your side with your knees slightly bent.
2. Turn your head at an angle of 450.
3. Remain in this position for 30 seconds.
4. Return to starting position.
5. Repeat all previous steps, but lie on the other side.
6. Take the starting position.

Between repetitions you should take a break of 10-15 seconds. 5 repetitions should be done in each direction.

Semont maneuver

This method of therapy should not be used at home, as the process may cause negative symptoms such as severe nausea and vomiting.

During the procedure, the specialist fixes the patient’s head at an angle of 450 with his own hands. At this time, the patient is in a sitting position. After fixing his head, he falls on one side and remains in this position for 2-3 minutes.

The next step is a sharp rise to the starting position and falling onto the other side. After this, the patient is fixed in position for 2 minutes. You need to fall down 4-5 times in each direction; there is no need to take breaks between approaches.

The entire time the patient changes his body position, the specialist does not remove his hands from his head. Many doctors are opposed to this method, but it brings results if performed correctly.

Epley maneuver

This type of therapy also involves performing it only under the supervision and assistance of a doctor. The patient's starting position is sitting on the couch with his legs dangling.

Next, perform the following steps:

1. The doctor fixes the patient's head with his hands.
2. After this, he suddenly falls onto his back, with his head hanging slightly off the couch.
3. The patient is in position for 2 minutes.
4. After this, the doctor carefully turns the patient’s head to one side, and the patient simultaneously tries to turn over on his side and is fixed in this position for 1 minute.

   

After this, the patient, with the help of a doctor, returns to the original position, the specialist does not let go of the person’s head all this time. After a 2-minute break, you can repeat the exercise, but after taking a horizontal position, turn your head in the other direction. You should complete up to 5 approaches in total.

Lempert maneuver

This technique is also used under the supervision of a doctor, but he himself does not fix the patient’s head. After taking the starting position, sitting with legs dangling, the patient independently turns on one side, then on his stomach and on the next side.

As a result, it rotates around its own axis. You should perform 6 full rotations, but slowly, holding each position for 1-2 minutes. You can take a break of 20 seconds between approaches.

Differential diagnosis

Dizziness is often a symptom of serious and dangerous illnesses that require immediate treatment. It is important to be able to distinguish paroxysmal vertigo from other diagnoses with similar symptoms. Often paroxysmal dizziness is a diagnosis of exclusion, when doctors conducted a thorough examination of the patient and did not identify organ pathology.

The main differences between the disease and other diseases of the nervous system are as follows:

• an attack occurs unexpectedly after a sudden change in body position or sudden movement of the head;
• the duration of the paroxysm is no more than 30 seconds;
• self-relief, after which the condition is completely normalized;
• absence of other symptoms and complaints.

Features

Positional vertigo, the causes of which can be different, differs from other types of pathologies accompanied by similar symptoms.

It can be differentiated by the following characteristics:

• Attacks of dizziness always begin unexpectedly. They do not depend on the time of day or other factors, and also end suddenly.

  

• During the day, repeated attacks do not develop, as with other diseases.
• After the disappearance of acute symptoms, the patient’s condition almost immediately returns to normal. This is not observed in other types of pathology.
• When the first symptoms of an attack appear, other general signs may be added that worsen the patient’s condition.

The rehabilitation period after an attack is quite short, which facilitates the course of the disease and does not provoke complications from other organs.

Symptoms

A classic episode of BPPV begins suddenly with a change in body position and tilt of the head towards the affected ear. After provoking movements, the patient begins a pre-attack period, which lasts less than five seconds. Then the attack itself begins - severe rotational dizziness. At this moment, the patient feels as if he is being thrown towards the affected ear. A person remains in this state for 30 seconds to a minute, after which the state of health returns to normal until the next provoking head movement.

The first attack of rotational vertigo for many occurs in the morning after waking up, when they try to get out of bed and sit down. This is due to changes in the position of the head and its rotation. However, if the patient, for example, gets up from the chair without moving his head, then the attack will not start.

BPPV manifests itself differently in everyone: minimal movement may cause nausea and vomiting in some patients, while in others the symptoms will be milder. In both cases, hearing loss, tinnitus, headache or other symptoms are not observed. And if the patient avoids provoking movements, then there are no symptoms at all.

During attacks, specific oscillatory eye movements occur - nystagmus. By assessing these movements, the side of the inner ear lesion is determined. During the period between attacks, when the position of the head is fixed, there is a feeling of cloudiness and fog in the head.

Usually, when communicating with a doctor, the first thing a patient says is that he is constantly dizzy, but upon more detailed questioning, it turns out that there is a clear division into two options: a period of active rotation and a period of a foggy state without rotation[5][6][9] [21][23].

A doctor is consulted with complaints of severe dizziness and disorientation in space, the occurrence of which is associated with a sharp change in body position. Sudden movements of the head, getting out of bed too quickly, bending over lead to a feeling of disorientation in space.

This is often accompanied by darkening of the eyes, flying “floaters” and spots in front of the eyes, slight stupor and loss of balance, which can cause you to trip or fall.

It is typical for benign paroxysmal positional vertigo that its duration lasts no more than 30 seconds, after which the condition returns to normal even if the body position that provoked the episode remains. It may also be accompanied by the following symptoms:

• nausea, less often vomiting;
• involuntary movement of the eyeballs, narrowing or dilation of the pupils;
• tachycardia and palpitations.

After an attack they also disappear completely. To do this, the patient just needs to stop moving, take a comfortable body position, or just stand quietly.

There are no problems with hearing or vision, and no complaints of headaches. Symptoms such as noise and ringing in the ears are not typical for this diagnosis.

Often, a characteristic symptom occurs when bending in any one direction.

Some patients note the onset of symptoms with a specific movement and their absence against the background of other movements.

Therapeutic measures to eliminate pathology and discomfort

Positional vertigo (causes may be related to osteochondrosis) can be successfully treated with gymnastics.

It is recommended to perform the following exercises:

• Tilts the head forward and backward.
• Head tilts in different directions.
• Acute rotation of the head clockwise and counterclockwise.
• Tilt the head forward and backward with a delay in each position for 10 seconds.

Each exercise must be repeated 10 times, pauses between them must be at least 10 seconds. It is better to do gymnastics before bed; it should not cause discomfort or severe pain.

The patient can perform this exercise independently at home.

To carry out this technique, the patient needs to sit in the center of the bed and bend several times from side to side. Then the patient is injected back into a horizontal position and repeats the movements in a supine position.

It is necessary to rest the body for a minute, then repeat the indicated Brandt Daroff exercises.

The method for treating the disease is repeated three times throughout the day. The duration of the procedure is determined individually depending on the general well-being of the patient.

Semont maneuver

This technique can be performed either independently or with the help of a qualified specialist.

The patient sits on the bed, the doctor takes the patient's head with both hands and turns it sharply, then injects it on the same side without changing the position of the head relative to the original plane.

The patient should lie down until all discomfort disappears.

After rest, without changing the fixed position of the patient’s head, the patient is returned to a sitting position, the head is turned and placed on the opposite side, the patient should also rest. This exercise is repeated 2-3 times, once a day.

In cases where a patient suffering from benign paroxysmal vertigo has a life history of pathologies from the cardiovascular system, cardiac tonic drugs are administered before the procedure as a specific predication.

If nausea and vomiting occur during the procedure, patients are prescribed antiemetic drugs.

Epley maneuver

A procedure of this nature is carried out only by qualified specialists. The peculiarity of this method is that the procedure is carried out using smooth and slow body movements.

The patient should initially sit on the couch, the doctor takes the head with both hands and fixes the head, turning it to the side in the same position, the patient’s head is placed on his back. After this, the person’s body is turned over on its side, and then slowly seated in its original position.

This method of non-drug treatment is very effective and in most cases, repeating two or three sessions can help completely get rid of the pathological condition.

The effectiveness of this method depends entirely on how professional the specialist performing this procedure is.

Lempert maneuver

This technique is carried out exclusively by a qualified specialist. The initial position of the patient should be sitting along the couch. Turning the head forty-five degrees, fix it in the plane of the horizontal body on the side of the focus of the pathological condition.

After this, the patient is placed in a supine position on his back and the position of the head is slowly changed in the opposite direction, then the head is turned to the other side and the position of the body is changed from back to stomach, while the head should rotate together with the human body.

The exercise can be repeated several times, but with the condition of maintaining a rest period.

Surgical intervention is performed in cases where conservative treatment of the disease has shown absolutely no positive results.

This treatment method is carried out very rarely and in quite exceptional cases.

For this purpose, surgical intervention techniques such as:

• filling the lumen of the semicircular bony canal of the inner ear with fragments from the bone structure, which is taken from another part of the skeleton of the human body. The most optimal bone for transplantation is the tibia;
• selective removal of nerve endings that innervate the vestibular canals of the human inner ear;
• total removal of structures and spongy substance of the bone labyrinth;
• destructive destruction of labyrinth structures using specially selected laser installations.

Absolutely all surgical methods are extremely traumatic for humans and therefore should be performed only for special medical indications.

After surgery, the patient must undergo antibacterial therapy in order to prevent the development of complications of an infectious nature.

To prevent dysentery as a side effect of antibiotics, the patient is prescribed probiotics in combination.

Causes

Scientists do not fully know the true reason for the appearance of otoliths in the endolymph. In 50% of cases, the cause cannot be identified, since paroxysms occur against the background of general well-being and good condition.

It is assumed that there is a hereditary predisposition, or the cause is associated with a congenital or acquired defect of the inner ear. In other cases, the reasons for the development of the diagnosis are the following conditions:

• traumatic brain injuries;
• infections and inflammatory processes in the ear;
• use of antibiotics with iatrogenic effects: tetracycline series;
• an increase in the volume of labyrinthine fluid in Meniere's disease;
• encephalopathy;
• disruption of the functioning of cerebral arteries;
• long bed rest;
• anesthesia;
• previous ear surgeries.

A direct connection with many ear defects has not been identified, but there has been an increase in the diagnosis of BPPV after organ damage.

Spreading

Positional vertigo occurs universally in people of all races. Most often diagnosed in women. People over 50 years of age are most susceptible to its development, but it is often diagnosed in young people and children.

Due to its benign course and mild symptoms, many do not seek medical help. This significantly distorts the true data on its prevalence. Also, due to insufficient qualifications of doctors and little knowledge of the pathology, many people mistakenly attribute it to other somatic conditions.

Despite this picture, there is an annual increase in the number of patients by 0.8%. Experts say that this is not due to an increase in morbidity, but to more frequent visits to doctors.

Complications of benign paroxysmal positional vertigo

Despite the benign course, in rare cases paroxysmal dizziness becomes more pronounced and progresses. This course is characterized by frequent severe attacks of disorientation, accompanied by severe loss of balance, vomiting and nausea.

Injuries resulting from falls are a common complication in the elderly. The pathological process does not affect other organs and does not affect the functioning of the ear. But many people develop various mental disorders: depression, anxiety disorder, manic-depressive psychosis and others.

Timely consultation with a doctor and treatment allows you to completely cure the disease and eliminate any complications that may arise.

BPPV itself has a favorable course, but if an attack of systemic dizziness occurs when a person is at great heights, depths, or while driving, then it can be dangerous. For example, such dizziness can cause a fall and injury.

The main complications and discomfort with BPPV are associated with the vestibular system. Autonomic disorders such as sweating and tachycardia are often observed. Patients experience prolonged minor instability both after an attack and after successful treatment.

Multichannel BPPV is one of the most severe complications. It can develop either after a head injury or after repositioning techniques—removal of otoliths and their particles from the canals. Crystals fall not only into the affected channel, but also into neighboring ones. This leads to severe irritation of the vestibular apparatus.

Do not forget that BPPV itself is a complication of other diseases, most often traumatic brain injury. It can be disguised as clinical manifestations of other diseases and injuries - vestibular neuronitis, heart attack or labyrinthine hydrocele. To distinguish BPPV from these disorders, it is necessary to take a competent approach to diagnosis.

What do you need to remember?

1. Benign paroxysmal positional vertigo is a defect of the inner ear that causes episodes of dizziness when moving the head.
2. Apart from short-term, up to 30 seconds, dizziness after changing body position, there are no symptoms.
3. Patients complain of sudden disorientation in space after moving their head.
4. In 50% of cases, the disease occurs for no reason; in other cases, the disease occurs due to head injury, ear inflammation, and infections.
5. More often diagnosed in older people.
6. The main diagnostic method is the Dix-Hallpike test.
7. Drug therapy is rarely used to treat BPPV due to the high number of adverse reactions.
8. A set of specially designed exercises will help prevent the development of attacks.
9. Pathology often leads to a disturbance in the patient’s mental state.

Literature

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• Palchun V. T., Guseva A. L., Chistov S. D. Benign paroxysmal positional vertigo: clinical aspects of diagnosis and treatment // Consilium Medicum. - 2020. - No. 3 T.17. — P. 46-52
• Kim JS, Zee DS. Clinical practice. Benign paroxysmal positional vertigo. N Engl J Med. 2014;370:1138-1147.
• Zamergrad M.V., Parfenov V.A., Melnikov O.A. Treatment of vestibular vertigo. Journal of Neurology and Psychiatry. S.S. Korsakov. 2008;108:11:86-92.
• Froehling DA, Silverstein MD, Mohr DN et al. Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota. Mayo Clin Proc. 1991;66:596-601. doi: 10.1016/s0025-6196(12)60518-7.
• Bestuzheva N.V., Parfenov V.A., Antonenko L.M. Diagnosis and treatment of benign paroxysmal positional vertigo in outpatient practice. Neurology, neuropsychiatry, psychosomatics. 2014;4:26-30.
• Kaski D, Bronstein AM. Epley and beyond: an update on treating positional vertigo. Pract Neurol. 2014;14:210-221. doi: 10.1136/practneurol-2013-000690.