For patients with "true spinning vertigo," how common is the diagnosis of BPPV and how successful are repositioning maneuvers when BPPV is diagnosed? How successful is vestibular rehabilitation therapy and what is the typical length of therapy?
Spinning vertigo can be divided into two separate categories: Subjective Vertigo and Objective Vertigo. Subjective vertigo refers to the complaint that the patient appears to be spinning while the environment appears to be steady. Objective vertigo refers to the complaint that the patient seems to remain steady but the environment is rotating about them. In either case there is conflicting sensory information that the brain interprets as movement, either of the environment or of the patient in relation to the environment. The perception is a hallucination caused by the sensory conflict.
The diagnosis of BPPV is not made based on the report of either subjective or objective vertigo alone. BPPV is a very specific diagnosis and must include objective (direct visualization of eye movement) and subjective (complaints of dizziness or vertigo when assuming a certain position) findings. The diagnosis of BPPV is made employing the Hallpike Maneuvering Test.
The Hallpike Maneuvering Test is accomplished in the following manner:
1.The patient is placed in a seated position on an examination table.
2. For the Hallpike-Right, the head is turned to the right and the patient is then rapidly placed in a supine position so that the head is hanging off of the table enough so that the head is lower than the shoulder. The patient is kept in this position for at least one minute.
3. The head is then turned to a forward position and the patient is rapidly returned to the seated position.
4. The Hallpike Left is performed the same way, with the exception that the head is turned to the left in Step 2.
The diagnosis of BPPV is made when there is a delayed onset (delayed relative to the head being placed in the hanging position) torsional (rotary) nystagmus in the direction of the downward ear observed by the examiner and there is a concomitant complaint of vertigo by the patient. The delay in onset of the rotary nystagmus and the complaint of vertigo can be as short as 2 seconds following the maneuver or as long as 45 seconds after. The nystagmus and the vertigo must abate within one minute. Upon returning the patient to the seated position there may be a brief episode of subjective vertigo and a reversal of the torsional nystagmus seen in the head-hanging position.
BPPV is the most common cause of vertigo due to peripheral pathology reported in the literature. In my practice approximately 40% of all patient with peripheral disorders are found to have BPPV.
The recommended treatment for BPPV is a procedure generically referred to as Canalith Repositioning Procedure (CRP). The procedure, first described by Semont and later expounded upon by Epley is also variously known as the Semont Procedure or the Epley Procedure. The distinction between these two procedures is not within the scope of this report. Successful outcomes have been reported in 85-95% of all cases of correctly identified BPPV. The CRP requires only about 20 minutes, or less, to complete, and only one treatment, in most cases, is required to resolve the problem.
CRP therapy should not be confused with Vestibular Rehabilitation. Vestibular rehabilitation is the treatment for patients with chronic non-resolved motion intolerance and imbalance problems. It is typically used for treatment of peripheral vestibular disorders other than BPPV.
Henry P. Trahan, Au.D., FAAA, CCC-A, is the owner and senior audiologist of ACI Hearing and Balance Center in Lafayette, Louisiana. He has been in private practice since 1984. He has taught audiology courses to both undergraduate and graduate students at the University of Louisiana - Lafayette and has been providing clinical practicum for audiology graduate students from The Louisiana State University, The University of Louisiana - Lafayette, and Florida State University. He is currently serving as adjunct faculty (facilitator) in the University of Florida Doctor of Audiology Distance Learning Program. He has authored several articles in audiology publications and made numerous presentations concerning vestibular testing and treatment at several regional audiology meetings.