eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Vertigo & Dizziness

Benign Paroxysmal Positional Vertigo: Treatment & Medication

Author: John C Li, MD, Private Practice in Otology and Neurotology; Medical Director, Balance Center
Coauthor(s): John Epley, MD, Director, Portland Otologic Clinic
Contributor Information and Disclosures

Updated: Sep 25, 2009

Treatment

Medical Care

Treatment options include watchful waiting, vestibulosuppressant medication, vestibular rehabilitation, canalith repositioning, and surgery.

• Watchful waiting: Since benign paroxysmal positional vertigo (BPPV) is benign and can resolve without treatment in weeks to months, some have argued that simple observation is all that is needed. Conversely, this involves weeks or months of discomfort and vertigo, with the danger of falls and other mishaps from the episodic vertigo spells (eg, patients who work on scaffolding may fall easily).
• Vestibulosuppressant medication: This medication usually does not stop the vertigo. Although it may provide minimal relief for some patients, it does not solve the problem; it only masks the problem. Adverse effects of grogginess and sleepiness also complicate the issue of medication.
• Vestibular rehabilitation: Vestibular rehabilitation is a noninvasive therapy that can have success after lengthy periods. Unfortunately, it causes repeated stimulation of vertigo while the patient is performing the therapeutic maneuvers. Patients can be instructed in Cawthorne exercises that seem to help by dispersing particles.
• Canalith repositioning: Since the benefit-to-risk ratio is so high with canalith repositioning, it appears to be the obvious first choice among treatment modalities.
• Particle repositioning is represented by two major maneuvers that developed simultaneously, yet independently, in the United States and France. These methods are the Epley maneuver and the Semont maneuver, and many minor variations of each of the methods exist. Both involve movements of the head to rearrange displaced particles. The Semont maneuver involves rapid and vigorous side-to-side head and body movements. The Epley maneuver is gentler and is described below. The canalith repositioning procedure (CRP) is a simple and noninvasive office treatment that is designed to cure BPPV in 1-2 sessions (see). This therapy, in experienced hands, has a success rate of more than 95% for patients with BPPV.

Recently, research into multi-axial positioning devices that can perform canalith repositioning using 360 degree rotation in the proper plane of the semicircular canals has been conducted. The results are promising, but these devices need more study.

• The Epley procedure is as follows (patient with right-sided BPPV in this example):

• Starting position (sitting, head turned 45° toward ipsilateral side): The patient begins the procedure in a sitting position with the head turned toward the affected side. A mastoid bone oscillator is applied and held in position behind the affected ear by a headband to help agitate the particles so that they move more easily.
• Position 1 (supine, head turned 45° toward ipsilateral side): The patient is reclined slowly to the supine position of the affected side. The rate is titrated to the point of no nystagmus and no symptoms. This usually takes approximately 30 seconds.
• Position 2 (supine, 15° Trendelenburg, head turned 45° toward ipsilateral side): The patient is reclined further to the Dix-Hallpike position of the affected side. This usually takes 10 seconds. Another 20 seconds are spent in the Dix-Hallpike position with the affected ear down.
• Position 3 (supine, 15° Trendelenburg, head turned 45° toward contralateral side): Next, the patient's head is turned slowly from position 3 toward the opposite side.
• Position 4 (lying on side with contralateral shoulder down, head turned 45° below horizon toward contralateral side): The body is rolled so that the shoulders are aligned perpendicularly to the floor, affected ear up. The head is then turned farther so that the nose points 45° below the plane of the horizon. This usually takes another 40 seconds.
• Position 5 (sitting, head turned at least 90-135° toward contralateral side): The patient is raised back to the sitting position with the head turned away from the affected side.
• Ending position: Finally, the head is turned back to the midline. The mastoid bone oscillator is turned off, and the headband is removed.
• A Dix-Hallpike test is performed immediately following the procedure. If nystagmus is observed, the procedure is repeated. After the procedure, the patient is instructed to avoid agitation of the head for approximately 48 hours while the particles settle and to return in 1 week for a follow-up examination.

Surgical Care

Surgery is usually reserved for those in whom CRP fails. It is not a first-line treatment because it is invasive and holds the possibility of complications such as hearing loss and facial nerve damage. Options include labyrinthectomy, posterior canal occlusion, singular neurectomy, vestibular nerve section, and transtympanic aminoglycoside application. All have a high chance of vertigo control.

Complete destruction of the affected inner ear is excessive, considering that only the posterior semicircular canal is involved. Therefore, the authors would not recommend labyrinthectomy or vestibular nerve section, except in the most extreme of cases.

Singular neurectomy, while theoretically a reasonable choice because it is directed at denervation of the offending posterior semicircular canal, is technically difficult and has only been mastered by a handful of surgeons. Furthermore, some of these patients have significant postoperative imbalance issues.

The most viable surgical option for patients who have failed CRP is posterior canal occlusion. The idea is to stop the benign positional vertigo by collapsing the posterior canal, immobilizing the movement of particles through the canal. This procedure is performed through a standard mastoidectomy approach. The offending posterior semicircular canal is isolated. The hard bone is drilled down with diamond burrs to expose the membranous labyrinth without spilling much perilymphatic fluid. The membranous labyrinth containing the endolymphatic fluid is compressed so that the flow of the length is disrupted. This keeps the particles from traveling through the endolymphatic space, thereby stopping the dizziness.

Success rates are in the 95th percentile range. Postoperative imbalance is not uncommon for a few weeks to months. This is typically treated with postoperative vestibular rehabilitation.

Activity

After CRP treatment, patients are instructed to avoid lying completely flat for 24-48 hours. Sleeping with the head elevated on a few pillows is recommended. Avoidance of jarring activities or gymnastic flips is recommended.

Medication

Vestibulosuppressant medication can be used to mitigate the severity of vertigo. Unfortunately, many times it is not effective and only masks the problem. Adverse effects of grogginess and sleepiness are also possible.

Although steroids have some beneficial effects in acute vertigo syndromes such as Ménière disease, they seem to have no value in the treatment of benign paroxysmal positional vertigo (BPPV).

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