Vertigo (cont.)
Benign paroxysmal positional vertigo (cupulolithiasis)
Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo. It
is characterized by severe episodes of vertigo associated with specific head
movement. Notably absent in BPPV are hearing loss, ringing of the ears
(tinnitus), and ear fullness. Patients often will describe vertigo after rolling
over in bed (usually to only one side) that often will awaken them from sleep.
Attacks will also occur after getting up from a bending position, tilting the
head back to shave the face or wash the hair, or reaching above the head to take
something from a high shelf. Vertigo usually occurs after a 1-2 second delay
following the provocative head movement. The vertigo is of short duration, often
less than 30 seconds. But many patients will describe a vague type of balance
problem (disequilibrium) between episodes.
BPPV increases with advancing age with an annual incidence of 10-50 cases per
100,000 population. There is a slight female predominance. The condition often
is associated with head trauma. BPPV is diagnosed clinically based on the
typical physical findings of positional vertigo and corresponding involuntary,
rapid, repetitive eye movements (nystagmus).
Dislodged tiny stones (cupulolithiasis) in the inner ear cause BPPV. These
stones are calcium carbonate crystals that are normally imbedded in a gelatinous
mass called the cupula. The cupula overlies the macula, which is a dense
structure in the wall of the two sacs -- the utricle and the saccule -- that
make up the vestibule. When the stones become dislodged, they float into the
semicircular canals of the inner ear. (See the figure.) In fact, microscopic
examinations of the inner ears from patients suffering with BPPV have
demonstrated these stones.
In the semicircular canals, the stones move from side to side, thereby
stimulating the canal. As a result, the canal signals the brain by way of the
ampullary branch of the vestibular nerve that it is measuring rotation.
Unfortunately, the other ear, the eyes, and the proprioceptive sensors of the
body are in mismatch, and the patient then experiences vertigo. Indeed,
surgically cutting across (sectioning) the ampullary nerve will immediately stop
the vertigo.
Treatment of BPPV is by physical therapy. Thus, repositioning maneuvers, such
as the Epley maneuver, are effective by moving the stones from the semi-circular
canals back to the cupula in the vestibule of the inner ear.
Next: Vertebral basilar insufficiency »
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