Quick Review for Patients

It is important to recognize that Benign Positional Paroxysmal Vertigo (BPPV) is responsible for at least fifty percent of all cases of vertigo and exercise therapy may be curative in up to ninety percent of patients. The primary therapeutic option is one form or other of exercise therapy. The severity of the individual attacks and accompanying nausea may be lessened by medical therapy, however, this does not prevent future attacks.

Exercise therapy is indicated for all patients with BPPV. There are two general approaches to therapy:

(a) a single treatment session in an outpatient office setting, (The Epley Maneuver and its variations) and

(b) a series of exercises performed by the patient at home (The Brandt-Daroff exercises). Each will be briefly described.

a). Office single treatment approach. Among the single treatment approaches are the Canal Repositioning Maneuver (CRP) and its modifications (Figure 9, Panel 1-6, Modified for this Web page exclusively, after Epley).

Figure 9. Positioning sequence for left posterior semicircular canal (in red) shows orientation of left labyrinth and gravitating canaliths (in violet).
1,The patient is seated with operator behind. An ultrasonic oscillator may be used and is started at this point.

2, Head is placed over end of table, 45 degrees to left, with head extended. (Canaliths gravitate to center of posterior semicircular canal, the "cleared" portion now shown in green.)
3, Head is rotated 45 degrees to right; head is kept well extended in process of coming from position 1. (Canaliths reach common crus.)

4, Head (and body) are rotated until facing downward 135 degrees from supine. (Canaliths traverse common crus.)

5, Patient is brought to sitting position; head is kept turned to right in process of coming from position 3. (Canaliths enter utricle.)
6, Head is turned forward with chin down about 20 degrees.

One standard protocol is described below. This technique works best for patients in whom a specific head position produces attacks of vertigo such as with the left ear down. Often times, the examiner notices a characteristic rotary vertical nystagmus accompanying the vertigo when the head is placed in the offending position (see Figures 3 and 4, earlier).

Treatment protocol for the left ear.

1. The patient is moved quickly from a seated position back over the end of the examination table with the head extended and turned approximately 45 degrees with the left ear down. In each position, there may be nystagmus induced as a result of change from the prior head position. The patient is kept in the position until the nystagmus or symptoms subside, typically ten to fifteen seconds.

2. The head is slowly rotated so that the right ear is now turned 45 degrees down, keeping the head extended.

3. The head and body are rotated to the right until the patient is facing downward. This position is maintained for approximately fifteen seconds.

4. The patient is then brought gradually up to a seated position with the head turned to the right.

5. The head is turned forward with the chin slightly depressed.

Over the next twenty-four to forty-eight hours, some recommend that the patient remain upright as much as possible. Another variation is to apply a handheld mechanical oscillator to the head in each position. The overall success of this single treatment is reported to be fifty to seventy-five percent.

b). Home Exercise Therapy (Brandt-Daroff exercises).

The patient is first instructed carefully about the type of exercise to be performed (Figure 10):

Figure 10. Exercise therapy: The patient begins in the seated position and then leans rapidly to the side, placing the head on the bed or table. The patient remains there until the vertigo subsides and then returns to the seated upright position, remaining there until all symptoms subside. The maneuver is repeated toward the opposite side, completing one full repetition. Ten to 20 repetitions should be performed two times a day.

Treatment Protocol for either ear.

1. In a seated position, on the edge of a couch or bed, the patient is asked to quickly lie on one side placing the worst ear (if one can be discovered) down first (Figure 10). The patient then moves from the sitting position, rapidly, and rest the head on a pillow or other support. They should not move so forcefully that it might produce a neck injury.

2. The patient then returns rapidly to an upright seated position and remains there for thirty seconds or until symptoms subside.

3. The patient rapidly lies down on the other side and remains there for approximately thirty seconds or until the symptoms subside.

4. The patient then returns to the upright seated position. This constitutes a single repetition.

Twenty repetitions should be performed two times per day. Each session lasts approximately thirty minutes. Some patients have intense symptoms at the onset of the BPPV, including vomiting. It is clear that the patients who experience extreme discomfort during the maneuvers will not be likely to pursue them on their own outside of an office or hospital setting. These patients may need hospital admission or hydration in an outpatient setting, with the concurrent administration of vestibular suppressant medications. Most patients' are willing to perform exercises at home. This protocol is particularly useful for BPPV patients who have the following:

1. Bilateral BPPV.

2. Uncertainty as to which ear is involved.

3. Failure of single office treatment protocols.

Recovery can be quite rapid occurring during the first few days of exercise therapy. Others progressively improve over weeks and months suggesting that the vestibular system may adapt to whatever abnormal perturbation is causing the symptoms.

Approximately fifty percent of patients who have well-defined vertigo and nystagmus in certain head positions will have improvement following the single treatment maneuver. Variations include the use of a handheld oscillator or longer durations in each single position. The home set of maneuvers, known as the Brandt-Daroff Maneuvers, may take days, weeks, or even months to produce a cure, but progressive improvement of symptoms should be noticed by the patient within the first few weeks. It is estimated that approximately twenty percent of patients have recurrences within the first year and either of the maneuvers described above may be repeated with high expectation of further improvement. The overall success rate of exercise therapy approaches ninety percent, even with patients who have been symptomatic for years.

Surgical Treatment of Peripheral Vestibular Disorders 

Surgical therapy of chronic peripheral vestibular dysfunction includes exploration for fistulas, endolymphatic shunts, and destructive end organ surgery. The details of these procedures may be found in standard otology texts. In patients with severe Meniere's disease for whom no medical therapy such as that described earlier has been effective, and who have severe recurrent disabling attacks, a labyrinthectomy may be performed. Unfortunately, Meniere's disease may become bilateral, eventually resulting in the need for labyrinthectomy or vestibular nerve section on the contralateral side. A medical labyrinthectomy may be performed by the use of aminoglycoside drugs, those particularly destructive to the peripheral vestibular hair cells. Surgical or medical labyrinthectomy is usually a last resort in patients who have clearly defined severe attacks of peripheral vestibulopathy, presumably from Meniere's disease.

Various shunting procedures have been used in the treatment of Meniere's disease or endolymphatic hydrops. Although some patients can benefit, the long-term success with such shunting procedures, which include shunts to the mastoid region and to the subarachnoid space, has been only modest.

Some patients with benign paroxysmal positional vertigo do not have a benign course. Patients who experience classic but disabling symptoms persisting over 6 months are candidates for exercise therapy as described earlier. On rare occasions, the exercise therapy is unsuccessful; such patients are candidates for section of the nerve from the posterior semicircular canal.