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BPPV is Over Diagnosed

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bppv-otoconia-cdWhat is BPPV?

BPPV (Benign Paroxysmal Positional Vertigo) is a common inner ear disorder that causes brief spells of vertigo (spinning sensation) triggered by a change in head position. For example, lying back or rolling over in bed, getting up from bed, looking up or down results in brief, 10-15 seconds of vertigo and usually no dizziness any other time. BPPV is caused by“crystals” normally present in one part of the inner ear, but become detached and displaced into another part of the inner ear where they cause vertigo with changes in head position. However, there are many patients diagnosed with BPPV who do not fit this description of symptoms or have a different cause of positional vertigo, yet are often diagnosed and unsuccessfully treated as though they had BPPV.

Why is BPPV Over-diagnosed?

BPPV has gained popularity as a diagnosis because it is a benign condition that causes vertigo and is readily diagnosed and immediately cured by a skilled healthcare provider. Patients often joke about “having a few loose rocks” in their head. BPPV is a common condition, but there are many more people diagnosed with BPPV than actually have BPPV.

How is BPPV Treated?

BPPV is treated by a “crystal repositioning maneuver” (CRM), which is designed to move the “crystals” by gravity back to where they originated, where they may be dissolved. The type of CRM utilized depends on the type of BPPV. For example, one form of BPPV is treated with a modified Epley or a Semont maneuver and another type with a Lempert roll. There is also a type of BPPV where the “crystals” are actually stuck to a membrane in the inner ear and is treated with a headshake of Gufoni maneuver. BPPV is no longer treated by the old fashioned Brandt-Daroff or Cawthorne-Cooksey exercises, or with medications, such as meclizine (Antivert). We are actually able to cure BPPV in one visit over 90% of the time with the appropriate CRM. Unfortunately, we see many patients incorrectly diagnosed with BPPV undergoing a modified Epley maneuver dozens of times unsuccessfully.

What else causes positional vertigo if it’s not BPPV?

Because migraine is the most common cause of dizziness/vertigo and can cause positional symptoms, the most common correct diagnosis in those mis-diagnosed with BPPV, is vestibular migraine. Other conditions which may cause positional dizziness include inner ear nerve weakness, blood pressure changes and even brain tumors. Obviously, it is very important to be certain of the cause of vertigo, as we don’t want to ineffectively treat for a condition that isn’t present and we don’t want to miss a more sinister cause.

Dizzy? It’s NOT a Tumor!

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Vestibular SchwannomaFeeling dizzy or having spells of vertigo (an illusory sense of motion usually described as ‘spinning’) can be quite troubling to most people. Of utmost concern is whether these symptoms represent something serious, such as a brain tumor. Rest assured, isolated symptoms of dizziness or vertigo are an extremely rare presenting sign of a brain tumor. To quote Arnold Schwarzenegger in ‘Kindergarten Cop’ (using his Austrian accent) “It’s not a tumor!”

Despite this, at least in the United States, it is the norm to proceed with a neuro-imaging study, such as CT or MRI, of the brain to “rule out” brain tumor, stroke, or multiple sclerosis (MS). There have been several studies concluding that doing CT and MRI scans for ‘dizziness’ or ‘vertigo’ in the absence of other neurologic signs or symptoms and in the absence of asymmetric hearing loss is not cost effective and rarely leads to a diagnosis.

Consider the following quote from Australian neuro-ophthalmologists who specialize in vestibular disorders:

“Balance disorders are common, while brain tumors are rare. An isolated balance disorder is thus rarely the presenting symptom of a brain tumor, and some physicians, particularly in countries infested with lawyers, worry about missing a brain tumor” – Hirose & Halmagyi, 1996

What country do you think they are referring to (“infested with lawyers”)?

On the other hand, vestibular function testing [which includes video-nystagmography (VNG), rotary chair, vestibular evoked myogenic potential (VEMP) and audiogram(hearing test)] assesses for both central (brain) and peripheral (inner ear) causes for dizziness and vertigo and can be quite helpful in localizing ‘where’, and then ‘what’ is causing the problem. Vestibular function testing has been demonstrated to be much more accurate and much more cost effective than MRI or laboratory tests in determining the cause of dizziness and vertigo.

‘Dizziness’ and ‘vertigo’ are symptoms, not diagnoses. Proper treatment of vestibular disorders is based on first determining the cause of dizziness or vertigo. Determining the cause of symptoms begins with a thorough history and physical examination followed by vestibular function testing in select patients.