Benign Paroxysmal Positional Vertigo Treatment & Management

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 were 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 the image below. This therapy, in experienced hands, has a success rate of more than 95% for patients with BPPV.

A retrospective study by Tirelli et al indicated that patients with recurrent BPPV who undergo repeated CRPs have a significantly increased dizziness recovery rate but do not have a significant difference in BPPV recurrence, compared with patients who have undergone an initial treatment with CRP but not repeated procedures. ^[10]

A retrospective study by Yoon et al of 1900 patients indicated that the following risk factors increase the chance that a patient with BPPV will need multiple CRPs: longer pretreatment duration of vertigo, involvement of bilateral or multiple canals, and age over 50 years. ^[11]

A study by Power et al found that 91% of cases of posterior canal BPPV were successfully managed with two canalith repositioning maneuvers or less, while 88% of cases of horizontal canal BPPV were effectively treated with two such maneuvers. A higher number of treatments were required for bilateral posterior canal and multiple canal BPPV, as well as for patients who experienced canal conversion. ^[12]

A literature review by Laurent et al indicated that in patients with BPPV, younger individuals need fewer canalith repositioning procedures (CRPs) than do older patients, with the average number of CRPs required for complete recovery being 1.4 for each patient in the younger group, compared with 1.5 in the older one. However, the younger and older groups did not significantly differ with regard to global treatment success of CRPs, the rates being 97.5% and 94.6%, respectively. ^[13]

Multi-axial positioning devices

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

Epley procedure

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.

The previously mentioned literature review by Anagnostou et al indicated that the anterior canal variant of BPPV can be successfully treated with the Epley and Yacovino maneuvers, as well as with various nonstandard maneuvers. The study, which included 31 citations, found a success rate of over 75% for each of these three types of maneuvers. ^[2]

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.

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.

A correlation has been demonstrated between the head-lying side during sleep and the side affected by benign paroxysmal positional vertigo. Patients may want to adjust their sleeping positions accordingly to prevent recurrence. ^[14]