In Barbara Kingsolver’s novel, Prodigal Summer, a character is plagued by sudden attacks of dizziness until an acquaintance shows him how to cure it by putting him through a series of manoeuvres. Benign positional vertigo (BPV) is a common and distinctive syndrome that usually affects those over 50. Patients complain of brief and intense bursts of vertigo brought on by changes in head position such as turning over in bed or looking up onto a shelf.

Suspicion of this diagnosis may be confirmed on physical examination with the Hallpike manoeuvre. The patient is laid back from a seated position to a lying position with the head hanging 30° below the edge of the table and turned 45° to one side. With the unaffected ear down, nothing unusual happens. When this is repeated with the affected ear down (observant patients can often tell you which way they have to turn their heads to bring on vertigo), there’s a latent period of some seconds and then the patient becomes intensely vertiginous and the examiner sees rotatory nystagmus with the upper pole of the eyes beating toward the floor. This lasts up to about 30 seconds. If this procedure is repeated, the response lessens each time so that by the third or fourth time, nothing happens. The Hallpike manoeuvre can be negative on one occasion and positive on another. Thus, in a patient with a typical history but negative examination, it can be useful to bring him or her back the next day and try again.

A popular theory of benign positional vertigo is that it’s caused by loose debris within a semicircular canal. The particle repositioning manoeuvre (Epley manoeuvre) is designed to move the debris out of the canal into a less irritating area of the inner ear. This begins with the Hallpike manoeuvre described above. Let’s assume that the right ear is the affected one and therefore the patient has nystagmus with the right ear down. Once the nystagmus and vertigo stop, the head is turned 90° to the left (i.e., left ear now down). The patient then rolls his or her body another 90° towards the left so that he or she is now looking down toward the floor. Milder nystagmus should now occur. Once this stops, help him to sit up and no nystagmus should occur. It’s recommended that the person attempt to keep the head upright as much as possible for the next couple of days. Cure rates on the order of 80% are quoted for this manoeuvre. But it’s not uncommon for BPV to recur.

Reference

1. Parnes et al. CMAJ 2003 Sep 30;169(7):681-93.

ENTER KEYWORD(S)

To search a phrase, use quotation marks (e.g. "back pain")