Benign Paroxysmal Positional Vertigo after Head Trauma

Benign Paroxysmal Positional Vertigo (BPPV) is a condition in which debris within the inner part of the ear interferes with balance. The medical term for this debris is otoconia, but it is commonly referred to as ear rocks.

Otoconia, or ear rocks, are calcium carbonate crystals that can become dislodged if there is a strong blow to the head. These crystals migrate into fluid filled semi-circular canals located in the vestibular system of the inner ear.

The canals of the vestibular system provide positional feedback to the brain. As the head moves, fluid flows through the canals which sends the brainstem information about where the head is located in relation to the rest of the body. The brain stem then sends a reflex to the eyes, to adjust their point of focus.

When the displaced crystals get into these canals, they interfere with the normal flow of the fluid. This results in the brain getting incorrect messages about where the head is positioned, and how it is moving. When the positional information coming from the ears, brain and eyes is not aligned, it leads to a variety of symptoms including:

  • Nausea
  • Dizziness,
  • Lightheadedness
  • Vertigo
  • Imbalance

These symptoms are most often experienced when the head is in motion, for example rolling over on one’s side, getting out of bed, turning the head to the side or tipping it back to look up. Any of these movements can lead vertigo, imbalance, and dizziness.

  

Depending on where the crystals are located, the symptoms may be present for several weeks, go away, and then suddenly reappear.

Diagnosing BPPV

Imaging tests will not show the crystals within the ear. Diagnosis is primarily made from the symptoms the affected person describes. There may also be observable signs.

For some individuals, the eyes will move inappropriately in response to the messages sent by the inner ear. This is called nystagmus.

Trained experts are able to turn a patient’s head in certain directions and observe for involuntary eye movements, in order to diagnose the condition. Nuances such as how long the vertigo and nystagmus last are also important when it comes to diagnosing BPPV

Treatment for BPPV

The goal of treatment is to get the crystals out of the fluid filled canals. This is possible through a procedure called Canalith Repositioning Maneuvers. The most common approach is called the Eppley Maneuver.

A trained medical specialist moves the patient’s head through a series of 4 positions to get the ear rocks to flow out of the semi-circular canals. Each position is held for about 30 seconds, and it is a painless procedure. It is effective about 70% to 80% of the time. If not successful, it can repeated.

After treatment, the patient will need to keep the head elevated for several days while sleeping.

Staying off of the “bad” side, the one that most often brought on symptoms, is also recommended.

In very rare circumstances, surgical intervention may be recommended. It is only attempted once all of the functional repositioning maneuvers have been tried several times.

One of the more common surgical procedures is called “posterior canal plugging.” During this procedure, the fluid filled canal that has the rocks is plugged. This stops the fluid from moving and sending confusing signals to the brain. The remaining fluid filled canals are left open, so the brain and eyes still get positional feedback.

This procedure is only necessary in about 1% of BPPV patients and is effective about 90% of the time.

Sources

Packer, R. (2014). The Incidence of Benign Paroxysmal Positional Vertigo (BPPV) in Patients Admitted to an Acquired Brain Injury Unit. Brain Impairment, 15(2), 146-155. doi:10.1017/BrImp.2014.16

Perez-Fernandez, N., Martinez-Lopez, M., & Manrique-Huarte, R. (2014). Vestibulo-ocular reflex in patients with superior semicircular canal benign paroxysmal positional vertigo (BPPV). Acta Oto-Laryngologica, 134(5), 485-490 6p. doi:10.3109/00016489.2013.871750

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