Before medical school, I worked as an assistant at the clinic of a physical therapist. Half of the physical therapist’s business was bread-and-butter physical therapy, but the other half was vestibular rehabilitation. The therapist specialized in diagnosing and treating balance and dizziness disorders of the inner ear. And guess what? Most of his patients were there as a last resort, because the doctors and their drugs weren’t working. They had fallen through the cracks, and the tragedy is that the most common cause for their dizziness is easily treatable, in 5 minutes, with only a table and some body positioning.
Benign paroxysmal positional vertigo, or BPPV, is caused by rogue calcium carbonate otoliths. These otoliths escape from the utricle of the inner ear and make their way into the semicircular canals (usually the posterior semicircular canal). These otoliths cause aberrant movement of the fluid in the semicircular canals with changes in head position, confusing the brain, which is getting mixed signals about the body’s orientation in space from the right and left semicircular canals. Predictably, the brain’s confusion manifests as vertigo, which defines as “an illusion of self or environmental motion.”
Patients with BPPV suffer from sudden dizzy spells triggered by changes in head position, usually lasting 15-20 seconds. Movements like looking up, rolling over in bed, or getting up out of bed in the morning set the world spinning, often with an accompanying nausea. As you can imagine, these patients do everything they can to minimize their head motion. They move in a characteristically rigid fashion, keeping their heads as still as possible in order to avoid repeat attacks. Clearly, this is an extremely unpleasant condition; one that is experienced at least once by 2.4% of the population. The good news, however, is that it is easily treatable, as long as it is recognized.
A certain amount of diagnostic finesse is required to rule out central nervous system problems, but once the proper neurological exams have been performed, BPPV should be high on the differential for patients with the symptoms described above. The test for BPPV is called the Dix-Hallpike Maneuver, in which the practitioner provokes a dizzy spell by changing the patient’s head position and observing the eyes for nystagmus.
Once a diagnosis has been made, treatment consists of The Epley Maneuver, which is nothing more than a simple series of head and body positions designed to use gravity to reposition the rogue otoliths into the utricle where they can no longer confuse the brain by moving semicircular canal fluid inappropriately. When the patients I saw were cured of their vertigo so quickly, with such a simple technique, they wasted no time in hailing the physical therapist I worked for as a miracle worker. They had been miserable for months, and that’s all it took to fix it?? In these situations, the patients were always ecstatic. I couldn’t help but smile.
As we go into rotations, residency, and practice, I hope we will be able to catch these patients before they fall through the cracks. My purpose in writing this article is to get the word out , because it is so easily treatable without the use of expensive, ineffectual, toxic medications. All we have to do is recognize it when we see it. As an added benefit, maybe someone will call you a miracle worker one day.
Harrison’s Principles of Internal Medicine, 19th Edition, Chapter 28
Vertigo by Diana Mehrez