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How to cite this article Bittar RSM, Mezzalira R, Furtado PL, Venosa AR, Sampaio ALL, Oliveira CACP.
Benign Paroxysmal Positional Vertigo (BPPV) is one of the most prevalent clinical disorders in common Neurotology practice and accounts for approximately 17% of complaints of vertigo1.
Given the noteworthy prevalence of BPPV, its health care and societal impacts are tremendous8. Positional vertigo is defined as a spinning sensation produced by changes in head position relative to gravity. Significant improvements in the diagnosis and treatment of patients with BPPV may lead to significant health care quality improvements as well as medical and societal cost savings. The purpose of this paper is to review the available methods for diagnosis and treatment of BPPV intended for clinicians who are likely to diagnose and manage patients with BPPV, and applies to any setting in which BPPV would be identified, monitored, or managed. Of the two variants of BPPV, canalithiasis is the most common, and the posterior semicircular canal is the most affected because of its anatomical position (85-95% of cases of BPPV)8. Recently, Gacek21 proposed a neural theory for BPPV, in which there was degeneration of the saccular ganglion secondary to a latent viral reactivation. Identifying the affected canal includes observation of the position that triggers the dizziness and the resulting type of nystagmus. When the patient gets in the position that triggers the dizziness, eye movement is observed resulting from the contraction of muscles related to the affected canal (slow component), followed by subsequent rapid correction in the opposite direction (fast component). In the vertical canals, there are excitatory connections to the ipsilateral superior oblique and contralateral inferior rectus to the posterior canal; ipsilateral superior rectus and contralateral inferior oblique to the superior canal, so that the arising movements are always rotational, but the nystagmus is vertical upward in the posterior canal and vertically downward in the superior canal23. The characterization of the nystagmus, allows the identification of the canal involved as well as the mechanism involved, and it is essential to choose the repositioning procedure. The Dix-Hallpike maneuver is considered the gold standard tool for the diagnosis of BPPV of posterior canal8.
The Dix-Hallpike maneuver is performed by the clinician moving the patient through a set of specified head-positioning maneuvers to elicit the expected characteristic nystagmus of posterior canal BPPV (Figure 1). The maneuver begins with the patient in the upright seated position with the examiner standing at the patient's side.
After resolution of the subjective vertigo and the nystagmus, if present, the patient may be slowly returned to the upright position. The particles present inside the semicircular canal undergo the effects of gravity and are shifted downward, and after a short latency, the liberating force created on the ampullar crista triggers the vertigo and nystagmus (Figure 2). In the case of the superior semicircular canal, a torsional downbeating nystagmus is exhibited. If the patient has a history compatible with BPPV and the Dix-Hallpike test is negative, the clinician should perform a supine roll test to assess for lateral semicircular canal BPPV8. Lateral canal BPPV (also called horizontal canal BPPV) is the second most common type of BPPV. In many instances, the presenting symptoms of lateral canal BPPV are indistinguishable from posterior canal BPPV. Due to an adaptation of the central nervous system8,26 or to the reversion of the direction of movement of the debris by the gravitational action26, it is not unusual that nystagmus spontaneously changes the direction without the head turning to the opposite side8,26. Additional exams are essential to clarify the trigger and associated features of BPPV1,15, 23,35. Imaging is not useful in the routine diagnosis of BPPV because there are no radiological findings characteristic of or diagnostic for BPPV8. Electronystmography has limited utility in the vertical canal BPPV diagnosis, since the torsional component of nystagmus cannot be registered by conventional techniques. Audiometry is not required for diagnosing BPPV, however it may offer additional information in cases where the clinical diagnosis of vertigo is unclear8. The treatment of BPPV is based on the performance of liberatory maneuvers or canalith repositioning procedures, with the aim of returning the displaced particles to their original location: utricular macula. A standard protocol, that is described in Table 3, is used in our service, considering the better results for each maneuver indicated for each BPPV variant. Some patients manifest severe symptoms with dizziness, nausea, sweating and vomiting while undergoing diagnostic or therapeutic maneuvers. The Epley maneuver39 is the most frequently performed repositioning maneuver of the vertical canal. According to the clinical practice guideline8, based on the review of the literature, it was not possible to determine the optimal number of cycles for the repositioning maneuvers.
The maneuver described by Semont41 is indicated for the treatment of posterior canal cupulolithiasis. Lempert42 described a maneuver (Barbecue Maneuver or Roll Maneuver) which is the most commonly employed maneuver for the treatment of lateral canal BPPV. Forced prolonged position is another treatment maneuver, described by Vannuchi44, for the treatment of lateral canal BPPV.
The Brandt-Daroff exercises were developed for home self-administration, as an additional therapy for patients who have been symptomatic, even after Epley or Semont maneuver40.
Many patients complain of imbalance during and between vertigo attacks, as observed by Celebisoy45.
The otolithic dysfunction induced by unequal loads of the macular beds has been considered as the underlying mechanism46. The repositioning maneuvers are associated to mild and self-limited adverse effects in about 12 percent of the treated patients8. During the course of repositioning maneuvers of vertical canals, the displaced particles could migrate into the lateral canal, in 6 to 7 % of the cases8. During the repositioning maneuvers, some patients develop severe, persistent vertigo, nausea, vomiting and nystagmus, which has the same features observed in the diagnostic maneuvers. The treatment consists of performance of the reverse maneuver, to aim to eliminate the blockade. By virtue of possible complications during the repositioning procedures, it is not a proper conduct to guide the patient self-treatment at home, without a physician.
After repositioning procedures, it is important to keep the patient in sitting position, for 10 minutes, to avoid falls51. Epley39, in his original paper, described the application of a bone conduction vibrator associated to repositioning maneuver, in order to release some adhered particles in the ampullar crista. The effectiveness of repositioning and liberatory maneuvers varies from 70% to 100%14,15,23,48. It is important to be careful when performing diagnostic, repositioning and liberatory maneuvers in obese patients, with limited cervical range of motion or with unstable heart failure or carotid stenois8,25,58.
Some authors believe in natural course of BPPV toward spontaneous relief48,59,60,61,62, which is possible in up to 89% of the patients in the first month, with subsequent recurrence in up to 33%, in three years37,38.
Thirty to 50 % of the patients have vestibular system dysfunction associated with initially treated BPPV, which can be demonstrated by caloric testing abnormalities. In daily clinical practice, it is seen that elderly patients complain most frequently of dizziness, tinnitus, and hearing loss. With an increase in the elderly population, the pattern of diseases changes, and the age factor has to be considered in diagnosis and treatment. In daily clinical practice, the elderly patients seen complain most frequently of dizziness, tinnitus, and hearing loss. In comparison to younger people, what is first noticeable about elderly people is that they have a good deal of body fat and a markedly low level of intracellular water. Listed in Table 2 are the diseases involving vertigo, which we often encounter in daily clinical practice, specifically among elderly patients.
The extension, flexion, or stenosis of a vertebral artery, cervical spondylosis, and cervical torsion due to the abnormality of cervical soft tissue induce rotary vertigo and sometimes a transient disturbance of consciousness.
For oral drug treatment, it is important to use such agents as clonazepam, imipramine hydrochloride, and thyrotropin-releasing hormone.
How to cite this article Pawlak-osi&# K, Ska , Ka&# H, Mierczak , Kuczy&# R, Ska , Szaflarska-pop&# A, et al. The aim of this study was to search for the reason for vertigo in children who complain of it.
Many children complain about vertigo but, in the majority of cases, vertigo seems to be a symptom accompanying other diseases and different from the strictly otoneurological phenomenon. The normal situation in our study was that children would present to a pediatrician, and the physician would notice vertigo among numerous other complaints. The otoneurological study consisted of detailed anamnesis according to Claussen, otolaryngological examination, videonystagmography (VNG), and posturography. Apart from the otoneurological diagnosis, the pediatrician collected the data from the physical examination and additional tests. Table 1 demonstrates the results of anamnesis and the additional tests ordered by the pediatrician to facilitate the pediatric diagnosis. The other problem was interpretation of positional nystagmus, present in 30% of our young patients.
Middle-ear diffusion and otitis media are the mostoften discussed reasons for vertigo and balance disturbances in children [16-18]. Such pathological factors as previous head injury, diseases of the cervical vertebral column, hormonal disturbances, lack of micro- and macroelements in the diet, and side effects of drugs prescribed for other diseases might be responsible for vertigo syndrome in those we tested. Wegener’s granulomatosis.18 TinnitusThe mechanism underlying tinnitus is not well-understood. Get full access to all EB Medicine articles published 3 years (or more) ago, including evidence-based, peer-reviewed diagnosis and treatment recommendations. I understand that we all experience dizziness and the onset of dizziness in different ways.
It is estimated that up to 25% of any population in the industrialized world will experience dizziness, with or without vertigo, at some point in their lives (1999 Prof. It is important to understand that all vertigo comes with dizziness, but not all dizziness comes with vertigo. The body senses its different positions and controls it’s balance through organs of equilibrium (balance) that make you feel stable, or normal. The semicircular ducts are arranged roughly at right angles with each other so that they represent all three planes in three-dimensional space. If you could take the upper portion of each inner ear on each side of the head, they would be symmetrical: the front canal on one side of the head is parallel to the rear canal on the other. Messages to the brain as to the head’s changes in position are generated by calcium carbonate crystals that shift on their bed of sensory hairs in the utriculus and the sacculus. The symptoms of true vertigo may include a very strong feeling that you are moving or spinning when you are actually still or that the room is moving about you. The cause of all vertigo is when the semi-circular canals are not functioning properly, ether due to infection, inflammation, trauma, hormonal imbalances, blood disorders, or scarring.
Meniere’s Disease is an inner ear disorder that brings spontaneous episodes of vertigo that can last minutes to hours. There are some changes to diet and lifestyle that may help you manage Meniere’s Disease.
Patients who suffer multiple episodes of severe vertigo without hearing loss likely have what is known as recurrent vestibulopathy.
There are some changes to diet and lifestyle that may help you manage this type of vertigo.
The vestibular system located in and around the ear controls our body’s sense of balance. Benign paroxysmal positional vertigo (BPPV) results from calcium carbonate (CACO3) particles that move freely within fluid in the canals of the inner ear.
Viral Labyrinthitis is a sudden disruption of the messages to the brain from within the inner ear as a result of a sudden viral infection.
Vestibular neuronitis is an inflammation of the vestibular nerve that causes a disruption of the message sent by the vestibular nerve to the brain.
It is important for people suffering from such symptoms to be examined and diagnosed by an ENT (Ear Nose Throat) specialist since other conditions, such as stroke can present with similar symptoms. This vestibular syndrome is characterized by transient attacks of vertigo, caused by change in head position, and associated with paroxysmal characteristic nystagmus.
It represents the most important peripheral vestibular impairment along the lifespan1,2,3, although the age at onset is commonly between the fifth and seventh decades of life4.
It is estimated that it costs approximately US$2000 to arrive at the diagnosis of BPPV, and that 86 percent of patients suffer some interrupted daily activities and lost days at work because of BPPV8. Benign paroxysmal positional vertigo is defined as a disorder in the inner ear, characterized by repeated episodes of positional vertigo8, with typical paroxysmal nystagmus. Despite its significant prevalence, and quality of-life and economic impacts, considerable practice variations exist in the management of BPPV across disciplines8.
Such improvements may be achievable with the reduction of the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of unnecessary tests such as radiographic imaging, and by increasing the use of appropriate cost effective therapeutic repositioning maneuvers. Displaced particles from utricule otoliths float around in the endolymph (canalithiasis)11 or adheren to the cupulae (cupulolithiasis)12 and may change the density relation of the cupulae-endolymph system.
The ampulla of the posterior semicircular canal is located in the lower region of the vestibule, both in the supine and standing position. Such reinfection could result in the loss of its antagonistic effect on the posterior semicircular canal. The classic complaint is vertigo in episodes, triggered by changes in the body position or head movements, lasting seconds and ceasing spontaneously. Each of the semicircular canals is directly connected to a pair of extrinsic muscles in the eye, having an excitatory and inhibitory influence, which determines the movement of the eyeball in the same plane as the canal24 (Table 1). This biphasic movement, called nystagmus, is a standard direction that is known as being the same as the fast component. In Table 2, we can observe the main features of involvement of different semicircular canals. Before beginning the maneuver, the clinician should counsel the patient regarding the upcoming movements and warn that they may provoke a sudden onset of intense subjective vertigo, possibly with nausea, which will subside within 60 seconds. During the return to the upright position, a reversal of the nystagmus may be observed and should be allowed to resolve8. Mechanism of displacement of the debris from the dome of the canal at rest and under the action of gravity (g), indicated by the arrow. The direction of the torsional component of the positioning nystagmus indicates which ear is the origin of nystagmus. Because this type of BPPV has received considerably less attention in the literature, clinicians may be relatively unaware of its existence and the appropriate diagnostic maneuvers for lateral canal BPPV8. The supine roll test is performed by initially positioning the patient supine with the head in neutral position, followed by quickly rotating the head 90 degrees to one side with the clinician observing the patient's eyes for nystagmus.
In canalithiasis, the movement of the head toward the affected ear promotes the displacement of free particles in the direction of the ampulla, triggering a horizontal nystagmus whose fast component will be toward the tested ear, so geotropic (towards the ground).
The mechanisms that initiate geotropic and apogeotropic eye movements can be seen in Figure 3. We can observe the mechanism of displacement of the ampullar crista that is responsible for the origin of geotropic nystagmus in canalithiasis(a), or for apogeotropic nystagmus in cupulolithiasis (b). De la Meilleure et al.26 reported the inversion of the horizontal nystagmus, in electronystagmography, in 75% of patients with BPPV of the lateral canal, always on the affected side. Further radiographic imaging may play a role in diagnosis if the clinical presentation is felt to be atypical, if the diagnostic maneuvers are unusual, or if additional symptoms aside from those attributable to BPPV are present, suggesting an accompanying modifying central nervous system or otological disorders8.
On the other hand in horizontal semicircular canal BPPV diagnosis, the nystagmus is present in the positional testing23.
These are non-invasive procedures that have been found to be long term effective for BPPV2,14. In these cases, vestibular suppressant medications are recommended as adjuncts not only to relieve the vertigo after maneuver but also to control the clinical symptoms until the procedure can be repeated4. The patient is placed in the upright position with the head turned 45 degrees to left when the left ear is affected.
If the posterior canal is affected, the patient is seated in the upright position; then the patient's head is turned 45 degrees toward the unaffected side, and then is rapidly moved to the side-lying position.

Demonstration of Lempert Maneuver sequence - treatment of lateral semicircular canal BPPV (right ear in black). This maneuver involves rolling the patient 360 degrees in a series of steps to effect particle repositioning8. The strategy consists of maintaining the forced lateral decubitus, with affected ear in the undermost position for 12 hours23,25.
Some authors indicate them one week before the therapeutic maneuver, aiming to improve the patient's tolerability14. This observation lead to the investigation of postural balance in patients with lateral and posterior semicircular canal BPPV. Other possibilities are the persistency of small amounts of residual debris in the canal, paresis of the ampullar receptors or the vestibular re-adaptation after peripheral disorder45. This phenomenon could result from a jamming of the otolithic debris (named jam) when migrating from a wider to narrower segment, such as from the ampulla to the canal or at the bifurcation of the commom crus50.
The use of a cervical collar, positional avoidance, or other restrictions are not necessary52,53,54. However, studies found no benefit in the BPPV treatment, since it does not modify the results of repositioning or liberatory maneuvers2,55,56,57.
The successful treatment is based on the identification of the affected semicircular canal, the distinction between cupulolithiasis and canalithiasis, the right choice of the most indicated maneuver2.
The spontaneous resolution is faster in the lateral semicircular canal BPPV than in posterior canal because the former spatial and anatomic orientation facilitates the return of the particles to their original place63,64.
Therefore, even if symptoms are typical of BPPV, the diagnostic maneuver has been positive, the repositioning maneuver has been successful, it is important that complete neurotological evaluation is obtained to rule out other vestibular disorders.
For the therapeutic maneuvers, correct diagnosis of the BPPV variant and affected semicircular canal is necessary. Central etiologies must be investigated when atypical nystagmus is found and therapeutic maneuvers are unsucessfully.
Bhattacharayya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, Chalian AA, Desmond AL, Earll JM, Fife TD, Fuller DC, Judge JO, Mann NR, Rosenfeld RM, Schuring LT, Steiner RWP, Whitney SL, Haidari J. In the ear, nose, and throat field also, we are required to consider changes in organs and diseases associated with age and corresponding treatment approaches.
In other words, elderly people are always at risk of dehydration and are liable to enter a shock state. Even if they have the same disorder as is seen in younger people, they are less likely to manifest typical symptoms. Hypotension produces rotary vertigo in patients, as it does paroxysmal positional vertigo (PPY). Hyperlipidemia, ischemic heart disease, and diabetes mellitus require special attention in the elderly, as does orthostatic hypotension.
Cerebellar infarction, particularly in the bilateral or median portion, often produces vertigo (Fig. The rare onset of this disease after the retirement age of between 60 and 65 years has to do with the decline of internal ear function with aging. Recall the familiar scene in which Robert Kennedy lay in the hotel lobby waiting for an ambulance immediately after he had been shot [4]. Of course, treatment should be provided on a case-by-case basis, but what is essential is to improve blood circulation.
In discussing such typical vestibular childhood diseases as benign paroxysmal vertigo, benign paroxysmal torticollis, basilar migraine, kinetosis, and visual-cliff phenomenon, we must be very mindful of parents' observations regarding other conditions (congenital anomalies, drugs, previous head trauma, and diseases treated currently and in the child's past) that can affect the balance system [1]. Because the pediatrician would order a test battery, including otoneurological examination, affected vertiginous children came to our otoneurological laboratory. Spontaneous nystagmus with eyes closed, optokinetic nystagmus, eye tracking, positional nystagmus, cervical nystagmus, and gaze nystagmus were assessed.
The posturographic test consisted of four sequences: with the platform moving backwardforward while the patient had eyes open and eyes closed, and with the platform moving side to side while the patient had eyes open and eyes closed. The most frequent assessments were blood and urine examination, spirography, gastroscopy, radiological testing of the cervical vertebral column, computed tomography or magnetic resonance imaging of the head, and neurological, ophthalmological, and psychiatric examinations. The maximum amplitudes were greater than normal (estimated in healthy children) when the platform moved side to side and backward and forward with the patient's eyes closed. Duwel and Westhofen [2] recommended videooculography as a method of choice in testing children. After excluding artifacts (repeating visuooculomotor tests several times), only 40% of the study group demonstrated a few pathologies. Many researchers question whether this kind of vestibular reaction is physiological in childhood and may be present in 20% of asymptomatic children [10]. We noted no pathology of the middle ear during routine otolaryngological examination in our children, nor did we observe any indication to perform tympanometry as a confirming test. The increase in maximum amplitude as compared with that in a normal sample in nearly each sequence of the entire examination may have been the effect of the changes in concentration; a small inattention may cause an abnormally greater deviation of the platform. Further, we questioned why the majority of cases manifested no objective signs of vestibulopathy during otoneurological examination. Gastritis and respiratory infections were the most frequent diseases that were accompanied by vertigo. Tinnitus is noise in the ear that may be heard on and off, continuously or in a pulsation form. These organs of balance are located in the inner ear and are called the semicircular canals. The horizontal duct lies in a plane pitched up approximately 30 degrees from the horizontal plane of the earth-erect head. The changes as to which hairs are being stimulated by the presence of crystals are reported to the cerebellum (a part of the brain) which in turn, translates the information into knowledge of the position of the head relative to gravity.
The subsequent inability of the middle ear to equalize air pressure in the middle ear chamber, causes undue pressure on the inner ear, and subsequently the semicircular canals where balance is registered.
Along with the vertigo, there may be some hearing loss in the affected ear that comes and goes, as well as an increase in tinnitus and a sense of fullness in the Meniere’s affected ear. Meniere’s Disease is felt to be due to an abnormality in the fluid balance of the inner ear. These include a low-salt diet to help reduce fluid retention as well as taking a medication that encourages urination (diuretics). These may include an anti-vertigo medication and anti-nausea agent to combat the sick feeling that comes with vertigo. When your head moves, the vestibular system sends information to the organs inside the ear, and these organs then pass the information on to the brain.
The cochlear nerve carries information about noise and hearing; the vestibular nerve carries information about balance and body position.
As a result of this virus, you may experience severe vertigo that usually comes on suddenly and can last from days to weeks, depending on the length of time the body builds up anti-bodies to the virus.
The first attack of vertigo is usually severe, and is associated with nausea and vomiting, lasting days to weeks. There are several medications that your physician may recommend if they feel that the vertigo associated with the vestibular neuronitis or viral labyrinthitis requires treatment.
The symptoms result from movement of the free floating otoconia particles in the endolymph or their attachment to the cupulae of the semicircular canal. These variations relate to both diagnostic strategies for BPPV and rates of utilization of various treatment options available for BPPV within and across the various medical specialties and disciplines involved in its management. In this context, BPPV should be mentioned not only because of the high prevalence, but also because of the relative simplicity of the diagnosis and cost effectiveness of the treatment9.
The semicircular canals change their gravitational orientation plane while the patients move their head. The fragments in suspension inside the labirinth tend to be deposited in this region, by the action of gravity1,13,14,15.
Typically, the vertigo arises in the lateral position of one or both sides, in hyperextension of the head, when standing up or lying down. Because the patient is going to be placed in the supine position relatively quickly with the head position slightly below the body, the patient should be oriented so that, in the supine position, the head can "hang" with support off the posterior edge of the examination table by about 20 degrees. The examiner rotates the patient's head 45 degrees to the left and, with manual support, maintains the 45-degree head turn to the left during the next part of the maneuver8. The Dix-Hallpike maneuver should then be repeated for the right side, with the right ear arriving at the dependent position. If the upper pole of the eye beats away from the ground toward the uppermost ear, then it originates from the anterior canal of the uppermost ear. Patients with a history compatible with BPPV (ie, repeated episodes of vertigo produced by changes in head position relative to gravity) who do not meet diagnostic criteria for posterior canal BPPV should be investigated for lateral canal BPPV. After the nystagmus subsides (or if no nystagmus is elicited), the head is then returned to the straight face-up supine position. When the head is rotated to the healthy side, the particles displace and lead to a current moving in the opposite direction from the ampulla (also generating geotropic nystagmus), and the stimulation is less intense than that observed on the affected side. Lee and colleagues27 described the spontaneous reversal of nystagmus bilaterally, and the primary phase of nystagmus was shorter and with greater velocity of the slow-phase. Other possible causes are ovarian hormonal dysfunction, hyperlipidemia, hypoglycemia or hyperglycemia, hyperinsulinemia, migraine, cervical trauma, otological surgery, sedentary and prolonged bed rest2,15,32,33,34.
Successful treatment depends mainly on the choice of the most appropriate maneuver for the case. The patient is rapidly laid back in a supine head-hanging position, which is maintained for a period of 1 to 2 minutes. The patient is in supine position; the patient's head is turned 90 degrees slowly toward the unaffected side.
The Brandt-Daroff exercises (Figure 8) are positioning exercises that, theoretically, promote habituation4. The treatment of each affected semicircular canal will be performed, in protocols according to the observed ocular movements and the correct identification of each affected semicircular canal.
Patients with posterior BPPV had impaired static balance ability when visual and proprioceptive inputs were inadequate as described by Celebisoy45, Di Girolamo46.
The conversion to lateral canal BPPV (so called canal switch) and Canalith Jam are unusual conditions, however when present must be promptly diagnosed and treated47.
In the Epley Maneuver, it happens when the head of the patient is turned to facedown position (Figure 5 - position c and d). If the patient develops important symptoms, vestibular suppressant medications may be considered to help in a later repositioning. Therefore, it is possible to propose to the patient to wait the spontaneous resolution, in cases where the maneuver can't be indicated. Benign paroxysmal positional vertigo: 10 year experience in treating 592 patients with canalith repositioning procedure. Neuro-otological features of benign paroxysmal vertigo and benign paroxysmal positioning vertigo in children: a follow-up study.
Free-floating endolymph particles: a new operative finding during posterior semicircular canal occlusion. Effectiveness of treatment techniques in 923 cases of benign paroxysmal positional vertigo. Benign paroxysmal positional vertigo due to a simultaneous involvement of both horizontal and posterior semicircular canals.
Monitoring of caloric response and outcome in patients with benign paroxysmal positional vertigo. Diagnostic, pathophysiologic, and therapeutic aspects of benign paroxysmal positional vertigo.
Reversal of initial positioning nystagmus in benign paroxysmal positional vertigo involving the horizontal canal.
Eletronytagmographic (ENG) findings in paroxysmal positional vertigo (PPV) as a sign of vestibular dysfunction. Canalith repositioning for benign paroxysmal positional vertigo: a randomized controlled trial.
The canalith repositioning procedure for treatment of benign paroxysmal positional vertigo.
A positional maneuver for treatment of horizontal-canal benign paroxysmal positional vertigo. Balance in posterior and horizontal canal type benign paroxysmal positional vertigo before and after repositioning maneuvers. Treatment efficacy of benign paroxysmal positional vertigo (BVVP) with canalith repositioning maneuver and Semont liberatory maneuver in 376 patients. Treatment of benign paroxysmal ositional vertigo: necessity of postmaneuver patient restrictions. Vibration with the canalith repositioning maneuver: a prospective randomized study to determine efficacy. The canalith repositioning procedure with and without mastoid oscillation for the treatment of benign paroxysmal positional vertigo. Natural course of the remission of vertigo in patients with benign paroxysmal positional vertigo. Natural history of benign paroxysmal positional vertigo and efficacy of Epley and Lempert maneuvers. Treatment of anterior canal benign paroxysmal positional vertigo by a prolonged forced position procedure. Diagnostic criteria for central versus peripheral positioning nystagmus and vertigo: a review. Against this background, we review vertigo in elderly patients briefly and consider the key points of its treatment.
Using this as backdrop, we review vertigo in elderly patients briefly and consider the key points of its treatment.
The dorsal root in the elderly is also degenerated, which ex-plains such diverse complaints as dizziness, tinnitus, ringing in the head, headache, neck and shoulder stiffness, and lumbago. Special effort should be made to differentiate between not only benign PPY but pseudobenign PPY and malignant PPY.
Atrial fibrillation, among others, can be one of the major causes for cardiogenic embolism [3]. The leftward conjugated deviation of the eyes and right facial palsy were due to a pontine lesion. The three keys are to facilitate blood circulation, prevent thrombosis, and improve blood rheology.
We performed the detailed protocol of anamnesis, videonystagmography, posturography, and additional tests ordered by the pediatrician and then compared the results of these procedures with those of a group of 30 healthy children. The goal of our study was to evaluate the reason for vertigo in children who complain of it. The caloric test was performed according to Brunings (with water at 30°C and 44°C) to search for unilateral labyrinthine weakness or directional preponderance (or both).
During each sequence, we measured four parameters: (1) maximum amplitude, (2) mean amplitudes of the platform deviations, (3) mean velocity of the platform sway, and (4) mean velocity of the head. Table 2 shows all the pathologies connected with the abnormal findings revealed by the pediatrician and other specialists and on the basis of additional tests. We used VNG and noted that the problem was with visuooculomotor reactions, during which not the equipment but both the immaturity of eye movement control and changes of concentration, smiling, and physical activity affected the recordings. In the literature, positional nystagmus is often connected with benign paroxysmal positional vertigo, but it must be emphasized that Hallpike's maneuver was not included in our VNG study, especially owing to the patients' lack of concentration and eye closing during position changes.
However, the other parameters-mean amplitude of the platform deviations, mean velocity of the platform sway, and head velocities-were in the normal range.
Fewer than one-half of those in the tested group demonstrated objective signs of vestibular disability during VNG. Caloric evaluation of the vestibular organ in the electronystagmography study determining dependence of vestibulo-ocular response.

Application of multivariate statistics to vestibular testing: Discriminating between Meniere's disease and migraine associated dizziness.
Sensory organization of balance responses in children 3-6 years of age: A normative study with diagnostic implications.
The front canals are located in vertical planes that project forward and outward by approximately 45 degrees. This feeling may become worse when you move your head, and it may make you feel nauseated or even make you vomit. However, for vertigo that lasts off and on or continuously for a few days, the following are some probable causes.
Often an anti-nausea agent is necessary to combat the sick feeling that comes with vertigo. Certain medications are effective in reducing the frequency and severity of vertigo attacks. This inner ear disorder is therefore similar to Meniere’s Disease, but without any hearing loss or noise in the ear. CACO3 crystals sometimes break away from the walls of the canals and circulate in the fluid. Viruses can affect either or both nerves and the symptoms will vary according to which nerve has been affected. The diagnosis is essentially clinical and should be confirmed by performing diagnostic maneuvers. Delays in the diagnosis and treatment of BPPV have both cost and quality-of-life implications for both patients and their caregivers8. The debris dislocates and promotes anomalous activation of the ampullar crista and may interfere with the neuronal output index that normally would be expected for that head and canal position. The lateral semicircular canal may be involved in 5 to 15% of patients8 and the anterior canal is rarely involved8; but there is still the possibility of simultaneous involvement of two canals18,19,20.
The examiner should ensure that he can support the patient's head and guide the patient through the maneuver safely and securely, without the examiner losing support or balance himself8. Next, the examiner fairly quickly moves the patient (who is instructed to keep the eyes open) from the seated to the supine left-ear down position and then extends the patient's neck slightly (approximately 20 degrees below the horizontal plane) so that the patient's chin is pointed slightly upward, with the head hanging off the edge of the examining table and supported by the examiner.
Again, the examiner should inquire about subjective vertigo and identify objective nystagmus, when present. After any additional elicited nystagmus has subsided, the head is then quickly turned 90 degrees to the opposite side, and the eyes are once again observed for nystagmus. Thus, the resulting eye movement is always stronger when the affected ear is placed downward23.
The arrows indicate the direction of displacement of the cupulae by gravity with the lateralization movement of the head. It has been proposed by Korres22 that the unilateral vestibular hypofunction is more common in cases secondary to head trauma or viral infection. Next, the head is turned 90 degrees, to the right (usually necessitating the patient's body to move from supine position to the lateral decubitus position). The jam generates a constant counter-attraction force in the cupulae, as result from negative pressure.
Possible explanations include some comorbidities and patient limitations during the maneuvers (for example: limited cervical range of motion or vascular failure)14. In comparison to younger people, what is first noticeable about elderly people is that they have a lot of fat in the body and a markedly low level of intracellular water. However, these complaints cannot be dismissed simply as an "unidentified syndrome." One or another organic disorder always is behind these complaints.
Because they are more or less conscious of death in daily life, they have a strong sensation of fear and thus visit with a variety of complaints. This tendency is particularly conspicuous among women, and their typical complaints include headache, vertigo, shoulder stiffness, palpitation, tinnitus, and lumbago (Table 1). When this vertigo is induced and associated with PPY symptoms, it is important to differentiate between benign and malignant forms (Fig. As compensation declines with aging, one usually becomes slower with age to recover from the same degree of disorder. This therapy should be continued for 10 consecutive days, followed by cessation for a subsequent 10 days.
Respiratory system infections, gastritis, and spondylosis were diagnosed most often by pediatricians in young people with vertigo. In one patient, epilepsy developed a few years later, and three were treated because of respiratory infections at the time of our study. In many of the VNG test results (discussed earlier), we observed only four pathological recordings: positional nystagmus, cervical nystagmus, pathological eye-tracking test results, and square waves regularly manifested during positional, cervical, and caloric nystagmus testing. This parameter was smaller than that in the healthy control group in nearly every sequence of the test. Our opinion on this topic was the same as that presented by Cyr [3] and Weeks [4], who stated that controlling the sinusoidal test, calibration, optokinetics, and gaze nystagmus in children is very difficult. In the cases in which the vestibular test results were abnormal, we searched for the causes, taking into consideration other test results collected during pediatric examination, and we observed a correlation between pathological VNG results and the presence of spondylosis.
Uneri and Turkdogan [11] noted benign paroxysmal positional nystagmus together with spontaneous nystagmus in 59% of children with vertigo, which, in their opinion, suggested a peripheral vestibular pathology. That being said I have noticed that we dizzies regardless of diagnoses describe many of the same sensations and share the same life altering effects that vestibular dysfunction causes. Dizziness in the form of light-headedness may result from a cardiovascular problem such as an irregular heart beat (arrhythmia) or if your blood pressure drops when you change positions (postural hypotension).
It often goes with many ear disorders, including Meniere’s Disease (see below), infections such as an inflammation of the middle ear (otitis media), or inflammation of the internal ear (labrynthitis), eustachian tube obstruction or noise-induced hearing loss. Their connections on one side are to the cochlea where they receive sounds, and to the aural nerves going to the brain. The rear canals are located in vertical planes that project backward and outward by approximately 45 degrees. The vertigo associated with Meniere’s Disease may happen suddenly, or may build in intensity over several hours and you may begin to experience nausea or vomiting. During and following a vertigo attack, the affected patient should avoid movements as they may increase the severity of the symptoms. There is no evidence of brain dysfunction with recurrent vestibulopathy, and it usually goes away over time.
When this situation occurs, a change in the head position i.e lying down, getting up, turning over in bed may cause the crystals that are freely floating to brush up against the hairs on the wall lining giving false messages as to the position of the head. Treatment is based on the identification of the affected semicircular canal and performance of liberatory maneuvers or repositioning of free floating particles of otoliths.
Some other symptoms could be associated and often persist after the interruption of the episode, such as nausea, imbalance, or postural instability1,15. The examiner observes the patient's eyes for the latency, duration, and direction of the nystagmus. Two potential nystagmus findings may occur with this maneuver, reflecting two types of lateral canal8. In cupulolithiasis, the fragments are adhered to the cupulae of the affected semicircular canal, which make them heavier than the endolymph. Some authors prefer to wait for the natural course towards a spontaneous relief, considering BPPV a self-limited condition.
The patient is rapidly moved to the opposite side-lying position without pausing in the sitting position and without changing the head position relative to the shoulder. Then, the head is turned to the facedown position and the body is moved to the ventral decubitus. The jam pressure induces cupulae displacement and consequent depolarization (vertical canals) or hyperpolarization (lateral canals).
In other words, elderly people are always at risk of dehydration and liable to enter a shock state.
Therefore, when we examine elderly patients, we need to pay special attention to various factors [1]. Because of brain atrophy with aging, they are less likely to present, for example, symptoms of increased intracranial pressure even if they have a brain tumor. Indeed, the eyes are the windows of the mind, they are more eloquent than lips, and they are a window for diagnosis. From videonystagmography results, we observed only four types of pathological reactions: positional nystagmus, cervical nystagmus, abnormal eye-tracking test results, and square wave abnormalities.
The children from the healthy group were never hospitalized, were never treated for otoneurological signs, and were examined regularly at school by balance testing (which is carried out according to each child's age and during which the child's weight, height, vision, hearing, and skin condition are checked). Claussen and Claussen [5] compared caloric examination in children 6-10 years old to that in children 11-15 years old.
Sahlstrand and Petruson [8] and Asaka [9] observed an exact connection between idiopathic scoliosis of the cerebral vertebral column and abnormalities during electronystagmography study. Zhang Zhao [12] demonstrated peripheral pathology in 95% of tested children younger than 13 years; benign paroxysmal positional vertigo or Meniere's disease was suspected in these cases. Some recurrent vestibulopathy may turn into Meniere’s Disease or benign paroxysmal positional vertigo (BPPV). The vertigo associated with BPPV comes on suddenly and usually only lasts for seconds to minutes.
Besides the clinical history, the diagnosis of BPPV takes into account the type, direction and duration of nystagmus provoked by maneuvers that provide clues for identifying the affected canal and the pathophysiological mechanism involved (whether canalithiasis or cupulolithiasis). Again, the provoked nystagmus in posterior canal BPPV is classically described as a mixed torsional and vertical movement with the upper pole of the eye beating toward the dependent ear. When the head is rotated to one side, the action of gravity on the ampullar crista moves the debris into the opposite direction and it is possible to observe the nystagmus that is in the opposite direction from the tested ear (apogeotropic type)24,25. Gradually the patient resumes the upright sitting position8.If the superior semicircular canal is affected, the movement is performed in the direction opposite to the procedure for posterior semicircular canal4,15,23,40. Later the patient's head is turned 90 degrees, and the body is placed on lateral decubitus. The dorsal root in the elderly is also degenerated, and this explains such diverse complaints as dizziness, tinnitus, ringing in the head, headache, neck and shoulder stiffness, and lumbago. When such patients have cerebral infarction, in particular, they experience a dizziness that is unexpectedly transient; thus, it requires careful attention. Cerebellar or pontine hemorrhage causes severe rotary vertigo, nausea and vomiting, tinnitus, and headache. They noted that in children in the younger group, the rotatory test is better accepted and is easier for clinical and statistical evaluation.
However, in their studies, positional and spontaneous nystagmus were dominant; in ours, the cervical test was a good indicator of cervical pathology.
Migraine was mentioned as the representative of nonspecific vestibulopathy in children, especially when positional nystagmus was accompanied by pathological eye-tracking test results and disequilibrium and when the typical episodic vertigo with headache sensitive to ergotamine appeared [13-15]. In our findings, the velocity of the platform was a paradox: It was smaller in patients with vertigo, confirming that they possessed a fairly good ability to control balance on a movable platform. We agree with the opinion that not only organic etiology but functional complaints must be considered in treating children with vertigo [21].
If you are lucky enough never to have had vertigo or dizziness due to vestibular issue then jump around with joy because you simply have not experienced true dizziness ( you lucky things).
Problems with chemical changes within your body (metabolic problems) may also cause dizziness, such as if your blood sugar drops too low (hypoglycemia) or hormonal imbalances.
Then the patient is asked to rest the chin on the shoulder and sit up slowly, completing the maneuver8 (Figure 4).
Figure 6 demonstrates the Semont Maneuver for treatment of right-sided posterior semicircular canal cupulolithiasis.
However, these complaints cannot be dismissed simply as "an unidentified syndrome." Behind these complaints is invariably one or another organic disorder. By contrast, cerebral hemorrhage causes nonrotary vertigo and is sel-dom associated with tinnitus.
In many cases, it progresses slowly after repeat transient ischemic attack and improves between episodes.
Kennedy, Robert Kennedy's fatal bullet penetrated through the right mastoid to the right cerebellar hemisphere. Posturography results did not provide specific findings as compared with those from the healthy children. In our data, one child demonstrated typical symptoms as mentioned-family history of migraine together with positional nystagmus and eye-tracking disability-so the diagnosis of vestibular migraine was suggested. Additional evidence suggests that generally our tested group was free from objectively measured signs of vestibular system diseases. Such complaints may depend on posttraumatic symptoms (even mild sleep disturbances), depression, neurosis, diet, and the side effects of antibiotics, steroids, and other medication therapy being administered for primary diseases (in our children, consisting of gastritis, bronchial asthma, etc.) [22]. The head must stay in that position for some moments, before it returns to the normal position1,4,23,40. Each step is maintained for 15 seconds - for slow migration of the particles, in response to gravity. Subarachnoid hemorrhage, which occurs from various causes, produces headache, vomiting, and dizziness.
We discussed the probable reasons for vertigo, among which psychogenic origin, side effect of medications, hormonal disturbances, spondylosis, and diet errors had to be taken into consideration.
To complete the maneuver, the patient is brought into the upright sitting position with head bowed down at 30 degrees23,43,44.
Muckelbauer and Haid [7] pointed out the differences between the various parameters among children from 5 to 14 years old. Taking into consideration these suggestions, our study was unexpectedly free from problems with the interpretation of caloric responses to bithermal stimulation: Every child demonstrated clear symmetrical reactions.
It is a scary, sweat inducing, heart racing experience that unfortunates like myself seem destined to encounter. Your spatial awareness, balance, cognitive ability and vision are temporarily or permanently ( as in my case) altered and you can no longer function normally. The level of disorientation can be overwhelming as it scrambles your senses into complete disarray. When you have a healthy vestibular system everything is fine and dandy, you wouldn't give your vestibular system a second thought ( hell, i didn't even know I had a vestibular system) but if something goes wrong, look out!Since my vertigo attack on Friday May 25th 2007 my symptoms have never left. They are present from the moment I open my eyes to the moment I go to sleep at night, they are never ever gone, I repeat They are never ever gone!!. This idea that you can possibly live with a never ending relentless illness with no let up day after day and year after year seems a very hard notion to grasp for many. It doesn't matter if you see me smiling, walking, watching TV or laughing, The fact is I am constantly enduring many uncomfortable sensations.
I am not experiencing short dizzy spells but constant, round the clock dizziness and vertigo. Simple tasks such as cooking, talking to another person for a length of time or brushing my teeth can up the intensity of my symptoms.
It is a list of symptoms published by the Vestibular Disorders Association and it describes my situation perfectly.I have modified the list somewhat to better suit my situation. Eyes feel stiff and slow▪ Discomfort from busy visual environments such as traffic, crowds, stores, and patterns. Supermarkets are terrible for increasing imbalance, disorientation and reducing cognitive ability due to the amount of visual stimuli.
Places with artificial lighting or a dark room, even a dull overcast day will increase all my symptoms such as the sensation of the floor lifting me up and down, my proprioception will be affected ( I will actually feel lost in space,floating).

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