Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is a common condition among elderly people and it increases their risk of falling.¹ BPPV is underdiagnosed and therefore undertreated in primary and community health services and the symptoms are frequently misinterpreted for symptoms of a sinister pathology such as stroke or brain tumour.

Causes of benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo is caused by displacements of otoconial debris from the otolith into one of the semi-circular canals within the vestibular system of the inner ear. Posterior canal BPPV, a common type, typically produces short episodes of vertigo, lasting less than a minute, provoked by positional changes of the head in relation to gravity such as lying down, looking up etc. Although it is not a life-threatening condition, it can cause considerable physical and psychological distress to the patient.

Diagnosis of benign paroxysmal positional vertigo

Posterior canal benign paroxysmal positional vertigo is diagnosed by the Dix-Hallpike test and treated by the Epley manoeuvre.²  The Dix-Hallpike manoeuvre is performed to diagnose BPPV. The patient is positioned on a couch in a long sitting posture with their head turned 45 degrees towards the side to be tested and is rapidly brought to supine lying with neck hyperextended to 30 degrees. If the test is positive, indicating the presence of BPPV, the patient will experience vertigo and the examiner will observe a particular pattern of repetitive eye movement.

The awareness among health professionals about the diagnosis and treatment of BPPV appears to be inadequate, since only a small percentage of patients with dizziness were referred to vestibular rehabilitation by GPs.³ It also takes approximately 92 weeks (14-202 weeks) for a BPPV patient to be successfully diagnosed and treated in the UK.³ Failure to do a simple clinical test can lead to multiple consultations (3-5 times) and unnecessary expenditures on unhelpful diagnostic investigations.⁴  Oghalai reported that 9% of elderly patients who attend hospital for various medical conditions have suffered with undiagnosed BPPV.⁵

Case report: benign paroxysmal positional vertigo in the older adult

History

An 84-year-old gentleman was referred to falls prevention service with chronic dizziness, frequent falls, poor balance, anxiety and decreased confidence. The patient described a two year history of vertigo, usually triggered by activities such as lying down, turning over in bed and looking up. This occurred on a daily basis and lasted typically a couple of minutes. He had consulted his GP a few times about dizziness and unsteadiness and his GP put him on 16mgs of betahistine, which he was taking three times a day.

A vestibular physiotherapist carried out the assessment in an out-patient clinic. The patient was walking with the aid of a stick and the assistance of his wife. Prior to physical examinations and special tests the patient completed a questionnaire to establish the extent of his self-perceived dizziness handicap, using the Dizziness Handicap Inventory (DHI), and he scored 98%, which indicated that his self-perceived handicap was very high.

Examinations of ocular range, smooth pursuit and saccades were normal and no spontaneous or gaze evoked nystagmus observed. Patient’s gaze stability was assessed with Head Thrust Test and it was normal. As a part of the vestibular assessment, he was tested for BPPV by performing the Dix-Hallpike test and the test was positive to the right side. Therefore a diagnosis of right posterior canal BPPV was established.

The patient was treated with the Epley manoeuvre on the same day following the diagnosis of BPPV. A repeat Dix-Hallpike was performed after half an hour of rest and found the test was negative, suggesting that the BPPV was cured.

Follow up

A review was carried out two months following the initial diagnosis and treatment and found that the patient was still experiencing some imbalance and fear of falling during walking, which was aggravated by his new pair of glasses. The patient was advised to attend the group exercise class run by community Falls Prevention Services to improve his balance and confidence and reduce the fear of falling, which he duly attended prior to the final follow up.

At the final follow up, the patient scored 14% in DHI scale, which is 84% lower than the initial measurement. The patient was discharged, after a total of three visits to the dizzy clinic with a complete cure of benign paroxysmal positional vertigo and improved balance and confidence.

BPPV is the most frequent of vestibular disorders in older people with dizziness. The cause is often idiopathic; however, ageing and an episode of labyrinthitis and head trauma due to a fall could dislodge the otoconial debris into the posterior canal and can cause benign paroxysmal positional vertigo . The patient demonstrated a complete recovery of BPPV following just one session of Epley manoeuvre and his perceived dizziness handicap dramatically decreased from 98% to 14%. Though the patient has been suffering from vertigo for over two years and was seen by his GP and other medical professionals, no tests had been performed to rule out or diagnose benign paroxysmal positional vertigo.

The patient was originally referred to the falls prevention service to manage his frequent falls and not specifically for vestibular rehabilitation for his dizziness. This reflects the conclusions made by others that only the small minority of patients with dizziness are referred for vestibular rehabilitation, probably due to lack of awareness among the GPs. The patient had been taking betahistine per day for his dizziness, without any significant improvement. Evidence advocates that vestibular suppressants should not be routinely used, on a long term basis, to treat patients with dizziness as they interfere with central compensation and can cause potentially harmful side effects, such as extrapyramidal symptoms.⁶

Conclusion

A vertigo attack in elderly people can imitate a cerebrovascular accident (CVA), where the latter should be given priority in diagnosis and management. However, benign paroxysmal positional vertigo should be tested for once CVA or any other sinister pathology is ruled out, especially if the patient continues to suffer with episodic vertigo.  The GP and allied health professionals should acquire adequate knowledge and skills to recognise the symptoms of BPPV in order that the condition can be effectively managed without unnecessary delay.

Conflict of interest: none declared

References

1. Lawson J, Bamiou D, Cohen HS, Newton J. Positional vertigo in a falls service. Age Ageing 2008: 37 (5): 585-88
2. Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003; 169: 681-93
3. Fife D, FitzGerald JE. Do patients with benign paroxysmal positional vertigo receive prompt treatment? Analysis of waiting times and human and financial costs associated with current practice. Int J Audiol 2005; 44: 50-57
4. John C Li, Li CJ, Epley J, et al. Cost-effective management of benign positional vertigo using canalith repositioning. Otolaryngol Head Neck Surg 2000; 122: 334-39
5. Oghalai JS, Manolidis S, Barth JL, et al. Unrecognised benign paroxysmal positional vertigo in elderly patients. Otolaryngology Head Neck Surgery 2000; 122: 630-34
6. Desloovere C. Medical treatment for vertigo. B-ENT, 2008; 4 (8): 59-62

Authors

Arokkiyasamy Selvanayagam, Dr Suliman Jawad, Sheeba B Rosewilliam