Benign positional vertigo treatment. Benign paroxysmal positional vertigo: causes, symptoms, treatment

Benign paroxysmal positional vertigo (BPPV) ranks first among all causes of vertigo.

It occurs when the position of the body changes, sometimes at the most unforeseen moments.

The nature of the occurrence of this symptom, methods of diagnosis and methods of treatment will be discussed later in the article.

Positional circling of the head can occur after a traumatic brain injury or a viral infection.

It may also appear after improper surgical treatment or as complications from antibiotic treatment (gentamicin).

The disease is always benign.

Periods of exacerbation can be repeated daily, but then there is a long period of remission, which can last several years. The disease can begin at any age.

Causes of positional vertigo

The vestibular apparatus is located in the inner ear, which is responsible for the orientation of a person in space. In anticipation inner ear there are special receptors that are attached to the otoliths and transmit information about all changes in the spatial arrangement of the body.

Benign positional vertigo is associated with displacement of the otoliths, as a result of which, when the position of the head changes, a feeling of dizziness appears. Particles of otoliths break off and enter the posterior canal of the inner ear, from where they cannot get out on their own due to the low location of the canal in any position of the human body.

If you notice the appearance of new, uncharacteristic symptoms for you, do not delay the visit to the doctor. Dizziness can be both an easily solved problem and a symptom of a more serious illness.

Symptoms

With positional vertigo, attacks usually appear suddenly and are of a short duration. May be associated with nausea and vomiting. The course of the period of attacks is difficult for a person, significantly reducing the quality of his life.

The suddenness of seizures can be life-threatening due to the likelihood of falling and injury, or, for example, seizures while driving. Symptoms are worse in the morning when lying down or when turning in bed.

Distinctive features of positional vertigo:

• the head is not constantly spinning, the symptoms appear in attacks;
• short term;
• nystagmus - rapid involuntary eye movements;
• accompanied by symptoms vegetative system- pallor, throwing into a fever, increased sweating, bouts of nausea;
• during the absence of an attack, the patient has no complaints, he feels good;
• after an illness, the body quickly returns to normal;
• with dizziness, there is often no tinnitus and a feeling of deafness, a headache rarely appears.

Forms of the disease

In DPPG, or otolithiasis, there are 2 forms:

1. Canalolithiasis is a clot of otolith fragments located in the smooth part of the canal.
2. Cupulolithiasis - fragments are fixed in the ampulla of one of the channels.

When establishing the diagnosis, the affected side and the semicircular canal are always indicated.

The suddenness of your symptoms should be alarming. Try to find a pattern so that you can tell the doctor about it later - a certain time for, the position of the body, a provoking factor.

Diagnostics

Diagnosis is quite simple and is based mainly on the complaints of the patient himself.

To confirm the diagnosis, the patient undergoes special tests.

For example, the Dix-Hallpike test. It is clinically significant that when the patient feels dizzy, involuntary eye movement is observed.

It is very important to correctly diagnose the occurrence of dizziness. There are cases when a patient has osteochondrosis cervical regions spinal or vascular problems in the brain and these factors were classified as the main cause of dizziness. At the same time, these were only concomitant diseases, since dizziness was caused precisely by the incorrect location of the otoliths and head turns.

Diagnosis is the most important step on the path to treatment. Be attentive to the sensations of your body so that the doctor can correctly determine the cause of dizziness.

Principles of treatment of positional vertigo

The main place in the treatment of benign positional vertigo is given to special positional maneuvers.

In this case, the doctor conducts a series of tilts and turns of the head in such a way as to achieve the cessation of the symptom.

For example, the Epley maneuver moves otolith particles from areas of the inner ear where they cause vertigo to other areas.

The maneuver can be carried out by both the doctor and the patient independently at home. The scheme of the maneuver is quite simple - you need to change your location five times, while tilting your head at a certain angle.

Medical treatment is ineffective. Existing drugs not able to eliminate an acute attack. In severe cases, in the absence of results after medical maneuvers, it may be indicated surgical intervention.

In general, the prognosis for the treatment of benign positional vertigo is favorable, and the effectiveness of treatment is high in most cases.

Constant and severe dizziness may indicate the presence of pathological processes in the body that are difficult to diagnose on their own. Here is a list of diseases that have this symptom.

Are vestibular exercises effective?

Vestibular exercises will help get rid of dizziness.

The patient is in this position or lying down for about 15 seconds, and then returns to a sitting position, but turns his head to the other side. Such exercises give a 75% positive effect.

Treatment for positional vertigo is up to you in most cases. Regular exercise and doctor's prescriptions - and you will get rid of this problem forever.

With benign positional vertigo, the main thing is to correctly diagnose it so as not to start erroneous therapy. Further recovery depends in most cases on the patients themselves - regular performance of special exercises and practically no financial expenses.

Age-related changes in the work of the vestibular apparatus can lead to dizziness. help to relieve the unpleasant symptom. See the list of recommended drugs.

Should you see a doctor if you experience mild dizziness from time to time? Let's look at the main causes of this syndrome.

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The content of the article

Definition

BPPV classification

• cupulolithiasis- the particles are attached to the cupula of one of the channels of the vestibular receptor;
• canalolithiasis- particles of the macula are located freely in the cavity of the canal.
• When formulating a diagnosis, one should also indicate the side of the lesion and the semicircular canal (posterior, anterior, external), where the pathology was found.

Etiology of BPPV

• injury
• neurolabyrinthitis
• Meniere's disease
• surgical operations (both general cavity and otological)

Pathogenesis of BPPV

The development of positional dizziness and nystagmus in patients with otolithiasis is due to the fact that the cupula of the sensory epithelium of the ampullary receptor deviates due to the "piston effect" of freely moving particles of the otolithic membrane or a change in its position due to sagging of the particles attached to it. This is possible when the head moves in the plane of the affected canal or the head and body at the same time.

Deviation of the cupula is accompanied by mechanical deformation of the hairs of the vestibular sensory epithelium, which leads to a change in the electrical conductivity of the cell and the occurrence of depolarization or hyperpolarization. In the unaffected vestibular receptor on the other side, no such changes occur and the electrical activity of the receptor does not change. At this moment, there is a significant asymmetry in the state of the vestibular receptors, which is the cause of the appearance of vestibular nystagmus, dizziness and autonomic reactions. It should be noted that with a slow change in the position of the head, the same slow movements of particles occur in the plane of the affected channel, which may not cause dizziness and positional nystagmus.

The “benignity” of dizziness is due to its sudden disappearance, which, as a rule, is not affected by the ongoing drug therapy. This effect is most likely associated with the dissolution of freely moving particles in the endolymph, especially if the calcium concentration in it decreases, which has been proven experimentally. In addition, particles can move into vestibule sacs, although this occurs spontaneously much less frequently.

Positional vertigo in BPPV is usually most pronounced after the patient wakes up, and then usually decreases during the day. This effect is due to the fact that acceleration when moving the head in the plane of the affected channel causes dispersion of the clot particles. These particles are dispersed in the semicircular canal, and their mass is no longer enough to cause initial hydrostatic changes in the endolymph during displacement, therefore, with repeated inclinations, positional vertigo decreases.

Clinic BPPG

Like a typical peripheral vertigo, an attack of BPPV may be accompanied by nausea and sometimes vomiting.

BPPV is characterized by the presence of specific positional nystagmus, which can be observed when an attack of positional vertigo occurs. The specificity of its direction is due to the localization of the particles of the otolithic membrane in a particular semicircular canal and the peculiarities of the organization of the vestibulo-ocular reflex. Most often, BPPV occurs due to damage to the posterior semicircular canal. Less commonly, pathology is localized in the horizontal and anterior canal. There is a combined pathology of several semicircular canals in one or both ears of one patient.

Important for the clinical picture of BPPV is complete absence other neurological and otological symptoms, as well as the absence of hearing changes in patients due to the development of this dizziness.

Diagnosis of BPPV

Physical examination

The Dix-Hallpike positional test is performed as follows: the patient sits on the couch and turns his head 45 ° to the right or left. Then the doctor, fixing the patient's head with his hands, quickly moves him to the supine position, while the patient's head, held by the doctor's hands, hangs over the edge of the couch by 45° and is in a relaxed state. The doctor observes the patient's eye movements and asks him if dizziness has occurred. It is necessary to warn the patient in advance about the possibility of the appearance of his usual dizziness and convince him of reversibility and safety. given state. The resulting nystagmus, typical for DPPG, necessarily has a latent period, which is associated with some delay in the movement of the clot in the canal plane or deviation of the cupula when the head is tilted. Since the particles have a certain mass and move under the influence of gravity in a liquid with a certain viscosity, the settling rate builds up over a short period.

Typical for BPPV is positional rotational nystagmus, which is directed towards the ground (geotropic). This is typical only for the pathology of the posterior semicircular canal. When looking away from the ground, one can observe vertical movements. Nystagmus, characteristic of the pathology of the horizontal channel, has a horizontal direction, for the pathology of the anterior channel - torsion, but directed from the ground (ageotropic).

The latent period (time from performing the tilt to the appearance of nystagmus) for the pathology of the posterior and anterior semicircular canals does not exceed 3-4 s, for the pathology of the horizontal canal - 1-2 s. The duration of positional nystagmus for canalolithiasis of the posterior and anterior canals does not exceed 30-40 s, for canalolithiasis of the horizontal canal - 1-2 minutes. Cupulolithiasis is characterized by longer positional nystagmus.

Always typical positional nystagmus BPPV accompanied by dizziness, which occurs with nystagmus, decreases and disappears with it too. When a patient with BPPV returns to their original sitting position, reversible nystagmus and vertigo can often be observed, directed in the opposite direction and, as a rule, less bright than when bending over. When the test is repeated, nystagmus and dizziness recur with proportionately reduced performance.

When examining the horizontal semicircular canal to determine BPPV, it is necessary to turn the head and body of the patient lying on his back, respectively, to the right and left, fixing the head in extreme positions. For BPPV of the horizontal canal, positional nystagmus is also specific and is accompanied by positional vertigo.

Patients with BPPV experience the greatest imbalance in the standing position at the moment of tilting or turning the head in the plane of the affected canal.

Instrumental Research

Differential diagnosis of BPPV

The central positional nystagmus is characterized primarily by a special direction (vertical or diagonal); fixing the gaze does not affect it or even enhances it: it is not always accompanied by dizziness and is not exhausted (it lasts all the time while the patient is in the position in which he appeared).

Positional nystagmus and dizziness may accompany multiple sclerosis and vertebrobasilar circulatory failure, but neurological symptoms characteristic of both diseases are recorded.

Treatment of BPPV

Non-drug treatment

1. Brandt-Daroff method. Often performed by the patient on their own. According to this technique, the patient is recommended to perform exercises three times a day, five tilts in both directions in one session. If dizziness occurs at least once in the morning in any position, the exercises are repeated in the afternoon and evening. To perform the technique, the patient must, after waking up, sit in the center of the bed, hanging his legs down. Then he is laid on one side, while the head is turned up by 45 °, and is in this position for 30 seconds (or until the dizziness stops). After that, the patient returns to the initial sitting position, in which he stays for 30 seconds, after which he quickly lays down on the opposite side, turning his head up by 45 °. After 30 seconds, he takes the initial sitting position. In the morning, the patient performs five repetitive inclinations in both directions. If dizziness occurs at least once in any position, the slopes must be repeated in the afternoon and evening.
   The duration of such therapy is selected individually. It cannot be completed if the positional vertigo that occurs during the Brandt-Daroff exercises does not recur within 2-3 days.
2. Semont's maneuver. Performed with the help of a doctor or independently. Starting position: sitting on the couch, legs hanging down. While sitting, the patient turns his head in a horizontal plane by 45° to the healthy side. Then, fixing the head with hands, the patient is laid on his side, on the affected side. He remains in this position until the dizziness stops. Further, the doctor, quickly moving his center of gravity and continuing to fix the patient's head in the same plane, lays the patient on the other side through the "sitting" position without changing the position of the patient's head (i.e. forehead down). The patient remains in this position until the dizziness completely disappears. Further, without changing the position of the patient's head, he is seated on the couch. If necessary, you can repeat the maneuver. It should be noted that the peculiarity of this method is the rapid movement of the patient from one side to another, while the patient with BPPV experiences significant dizziness, vegetative reactions are possible in the form of nausea and vomiting; Therefore, in patients with diseases of cardio-vascular system this maneuver should be performed carefully, resorting to sedation if necessary. To do this, you can use betahistine (24 mg once 1 hour before the procedure). In special cases, thiethylperazine and other centrally acting antiemetics are used for premedication.
3. Epley maneuver(with pathology of the posterior semicircular canal). It is advisable that it be performed by a doctor. Its feature is a clear trajectory, slow movement from one position to another. The starting position of the patient is sitting along the couch. Previously, the patient's head is rotated 45° in the direction of the pathology. The doctor fixes the patient's head in this position. Next, the patient is placed on his back, head tilted back by 45°. The next turn of the fixed head is in the opposite direction in the same position on the couch. Then the patient is laid on his side, and his head is turned with a healthy ear down. Next, the patient sits down, the head is tilted and turned towards the pathology, after which it is returned to its usual position - looking forward. The patient's stay in each position is determined individually, depending on the severity of the vestibulo-ocular reflex. Many professionals use additional funds to accelerate the settling of freely moving particles, which improves the effectiveness of the treatment. As a rule, 2-4 maneuvers during one treatment session are enough to completely stop BPPV.
4. Lempert maneuver(for BPPV of the horizontal semicircular canal). It is advisable to have a doctor do it. The starting position of the patient is sitting along the couch. The doctor fixes the patient's head during the entire maneuver. The head is turned by 45° and the horizontal plane towards the pathology. Then the patient is laid on his back, successively turning his head in the opposite direction, and after that - on a healthy side, the head, respectively, is turned downwards with a healthy ear. Further, the patient's body is turned in the same direction and placed on the stomach; the head is given a position with the nose down; as it turns, the head turns further. Following this, the patient is placed on the opposite side; head - with a sore ear down; the patient is seated on the couch through the healthy side. The maneuver can be repeated. It is important that after performing the maneuver, the patient observes the mode of limiting inclinations, and on the first day sleeps with the head of the head elevated by 45-60°.

Surgery

• Filling of the affected semicircular canal with bone chips.
• Selective neurectomy of the vestibular nerves.
• Labyrinthectomy.
• Laser destruction of the labyrinth.

Benign paroxysmal positional vertigo (BPPV) is a vestibular disorder that occurs when the position of the body and head changes. The causes of this pathology are not fully understood. It is believed that BPPV is based on structural changes in the labyrinth of the inner ear as a result of any external influences. Women suffer from BPPV more often than men. The frequency of occurrence of this type of vertigo is quite high and amounts to 50% of all vestibular peripheral vertigo.

Mechanisms for the development of BPPV

Currently, scientists suggest two main theories of the origin of BPPV associated with the destruction of the otolithic membrane of the inner ear. These are cupolithiasis and canalolithiasis. In the first case, easily moving particles of the otolithic membrane are fixed on the dome of one of the channels, and in the second case, in its cavity. These particles have a small mass and tend to settle, but any movement of the head leads to their movement and causes an attack of dizziness. The best period for otolithic particles to settle is during the nocturnal sleep phase, when they form the so-called clots, which, upon awakening, cause hydrostatic changes in the semicircular canal. At the same time, these changes are absent on the opposite side.

The resulting asymmetry in the state of vestibular receptors leads to the development of pathological symptoms. It is believed that the basis of all these disorders is a violation of calcium metabolism. At the same time, provoking factors for the development of BPPV can be:

• traumatic brain injury;
• surgical interventions;
• infections;
• taking ototoxic antibacterial drugs(for example, antibiotics from the group of aminoglycosides);
• neurocirculatory dystonia, migraine, etc.

Over time, freely moving particles dissolve in the endolymph or move into the sacs of the vestibule of the inner ear and the patient recovers.

Clinical manifestations

BPPV is characterized by typical repetitive attacks of dizziness with a sensation of rotation of surrounding objects. Most often they occur in the morning after waking up or at night when turning in bed. It provokes an attack by moving the head from one position to another. In this case, dizziness has a greater intensity, but lasts no more than one minute. Often the attack is accompanied by nausea, vomiting and general anxiety. With a long course of the disease in persons suffering from BPPV, disorders of the balance function may appear.

In addition, during dizziness, patients have another specific symptom - nystagmus (oscillatory involuntary movements eyeballs). It may have a different direction depending on the location of the affected semicircular canal. More often, BPPV occurs with localization pathological changes in the posterior semicircular canal.

A distinctive feature of this pathology from other forms of dizziness is the absence of other neurological symptoms and normal hearing.

Diagnostics

The diagnosis of BPPV is based on clinical manifestations diseases. With an objective and additional examination, pathological changes are usually not detected. Special positional tests help the doctor confirm the diagnosis. For example, the Dix-Hallpike test. Before it is carried out, the subject is in a sitting position and turns his head in any direction by 45 degrees. Then the doctor fixes his head and quickly moves him to the prone position (while the head hangs from the edge of the couch), and then observes the movement of the patient's eyes and his condition. The resulting nystagmus and an attack of dizziness indicate the presence of BPPV in the patient.

Be sure to carry out differential diagnosis with pathology of the posterior cranial fossa, central positional nystagmus, multiple sclerosis and vertebrobasilar insufficiency.

Conservative therapy

Treatment of BPPV is aimed at stopping attacks of dizziness as soon as possible. For this, the method can be used therapeutic effect using special maneuvers that promote the mechanical movement of free particles in the semicircular canals. Maneuvers are a set of exercises that can be performed independently or with the participation of the attending physician. It should be noted that the latter are more effective (cure occurs in 95% of cases).

At home, such patients can use the Brandt-Daroff technique. Its essence is to perform the exercise 3 times a day, five inclinations in each direction.

• To carry out the maneuver, a person after waking up needs to sit in the center of the bed, while lowering his legs.
• After that, you need to turn your head at an angle of 45 degrees to the left (or right) and lie on the same side.
• It is recommended to be in this position for 30 seconds or until the attack completely ends (if any).
• The same is recommended to repeat with a turn of the head to the other side.

The duration of such therapy is determined on an individual basis, its effectiveness is about 60%. With high vegetative sensitivity, betahistine and antiemetics may be prescribed to patients for the period of maneuvers.

Other therapeutic maneuvers are carried out under the supervision of the attending physician, as they can cause severe autonomic attacks and are technically more complex. An example of such an impact can be the Lempert method.

• For its implementation, the patient sits down on the couch in the direction along it.
• The doctor fixes his head for the duration of the entire procedure and first turns it 45 degrees towards the lesion in the horizontal plane.
• Then the patient moves to the back and the head turns to the other side.
• Next, the patient turns over on a healthy side with the ear down.
• Then - on the stomach and then on the opposite side, while the head moves along the turn.
• At the end of the maneuver, the patient is seated on the couch through the healthy side.

Surgery

With the ineffectiveness of conservative methods and too long adaptation, it is possible surgery BPPG. The most effective and safe procedure is filling the affected canal with bone chips.

Other surgical interventions (removal of the affected labyrinth, transection of the vestibular nerve) can also be used, but they have a number of complications and lead to destruction of the structures of the inner ear.

In some patients (in 6% of cases), relapses of the disease are possible, in which case it is necessary to limit movement in space and consult a doctor as soon as possible.

Conclusion

The occurrence of BPPV can disrupt the normal life of patients and even deprive them of their ability to work. But because these disorders are called benign, their characteristic feature is the sudden disappearance of all symptoms. Treatment of BPPV is prescribed if it is difficult to tolerate by patients and persists. long time. And in most cases, the results are not long in coming.

Otorhinolaryngologist A. L. Guseva presents a presentation on the topic "BPPV":

Neurologist Kinzersky A.A. talks about benign pparoxysmal positional vertigo:

Benign paroxysmal positional vertigo is a disease of the vestibular apparatus characterized by sudden attacks dizziness. Four words from the name carry the main essence of this problem: “benign” means the absence of consequences and the possibility of self-healing, “paroxysmal” indicates the paroxysmal nature of the disease, “positional” indicates dependence on the position of the body in space, and “dizziness” - main symptom. However, the apparent simplicity hides many subtleties. You can learn about everything related to benign paroxysmal positional vertigo, about the basic information and subtleties of this disease by reading this article.

In general, it is a very non-specific symptom. Offhand, you can name more than 100 diseases that can manifest themselves as dizziness. But benign paroxysmal positional vertigo has some clinical features, due to which the correct diagnosis can be established already during the initial examination by a doctor.

Benign paroxysmal positional vertigo (BPPV) is considered a fairly common disease. Western European countries give out the following statistics: up to 8% of their population suffers from this disease. The CIS countries, unfortunately, do not have reliable statistics on this problem, but they would hardly differ significantly from European ones. Up to 35% of all cases of vestibular vertigo can be associated with BPPV. The numbers are impressive, aren't they?

BPPV was first described by the Austrian otolaryngologist Robert Barani in 1921 in a young woman. And since then, the symptoms of BPPV have been isolated as a separate disease.

Causes and mechanism of development of BPPV

To understand why and how this disease develops, it is necessary to delve a little into the structure of the vestibular apparatus.

The main part of the vestibular apparatus are three semicircular canals and two sacs. The semicircular canals are located almost at right angles to each other, which makes it possible to record human movements in all planes. The channels are filled with liquid and have an extension - an ampoule. The ampulla contains a gelatin-like substance cupula, which has a close relationship with receptors. The movements of the cupula, together with the flow of fluid inside the semicircular canals, create a sense of position in space in a person. The upper layer of the cupula may contain calcium bicarbonate crystals - otoliths. Normally, throughout life, otoliths are formed and then destroyed during the natural aging of the body. Destruction products are utilized by special cells. This situation is normal.

Under certain conditions, used and obsolete otoliths do not break down and float in the form of crystals in the liquid of the semicircular canals. Appearance additional items in the semicircular canals, of course, does not go unnoticed. The crystals irritate the receptor apparatus (in addition to the normal stimuli), which results in a feeling of dizziness. When the crystals settle in any area under the influence of gravity (usually the sac area), then the dizziness disappears. The described changes are the main mechanism for the occurrence of BPPV.

Under what conditions are otoliths not destroyed, but sent to “free swimming”? In half of the cases, the cause remains unexplained, the other half occurs when:

• (due to traumatic separation of otoliths);
• viral inflammation of the vestibular apparatus (viral labyrinthitis);
• surgical procedures on the inner ear;
• taking ototoxic antibiotics of the gentamicin series, alcohol intoxication;
• spasm of the labyrinthine artery, which supplies blood to the vestibular apparatus (for example, with migraine).

Symptoms

BPPV is characterized by specific clinical features that underlie the diagnosis this disease. So, BPPV is characterized by:

• sudden attacks of severe dizziness that occur only when changing the position of the body, that is, dizziness never appears at rest. Most often, an attack provokes a transition from a horizontal to a vertical position after sleep, turns in bed in a dream. The leading role in this case belongs to a change in the position of the head, and not the body;
• dizziness can be felt as the movement of one's own body in space in any plane, as the rotation of objects around, as a feeling of falling or lifting, swaying on the waves;
• the duration of the attack of dizziness does not exceed 60 seconds;
• sometimes dizziness may be accompanied by nausea, vomiting, slowing down heart rate, diffuse sweating;
• an attack of dizziness is accompanied by nystagmus - oscillatory involuntary movements of the eyeballs. Nystagmus can be horizontal or horizontal-rotational. As soon as the dizziness stops, the nystagmus immediately disappears;
• attacks of dizziness are always the same, never change their "clinical coloring", are not accompanied by the appearance of other neurological symptoms;
• attacks are more pronounced in the morning and in the first half of the day. Most likely, this is due to the dispersal of crystals in the fluid of the semicircular canals during constant head movements. Crystals break into smaller particles in the first half of the day (motor activity is much higher during wakefulness than during sleep), so in the second half the symptoms practically do not occur. During sleep, the crystals "stick together" again, leading to an increase in symptoms in the morning;
• on examination and careful examination, no other neurological problems are ever found. There is no tinnitus, no hearing impairment, no headache - no additional complaints;
• spontaneous improvement and disappearance of dizziness attacks are possible. This is probably due to the independent dissolution of detached calcium bicarbonate crystals.

BPPV is more common in people over 50 years of age. Perhaps by this time natural processes resorption of calcium bicarbonate crystals slows down, which is the reason for the more frequent occurrence of the disease at this age. According to statistics, women suffer from BPPV 2 times more often than men.

Diagnostics

Clinical Features BPPV allow you to come close to the correct diagnosis already at the stage of questioning the patient. Clarification of the time of occurrence of dizziness, provoking factors, the duration of attacks, the absence of additional complaints - all this suggests BPPV. However, more reliable confirmation is needed. For this purpose, special tests are performed, the most common and simple of which is the Dix-Hallpike test. The test is carried out as follows.

The patient is seated on the couch. Then they turn (do not tilt!) The head to one side (presumably towards the affected ear) by 45 °. The doctor, as it were, fixes the head in this position and quickly lays the patient on his back, maintaining the angle of rotation of the head. In this case, the patient's torso should be positioned in such a way that the head hangs slightly over the edge of the couch (that is, the head should be slightly tilted back). The doctor observes the patient's eyes (in anticipation of nystagmus) and at the same time asks about the sensation of dizziness. In fact, the test is a provocative test for a typical BPPV attack, since it causes a displacement of crystals in the semicircular canals. In the case of BPPV, nystagmus and typical dizziness occur approximately 1-5 seconds after the patient is laid down. The patient is then returned to the sitting position. Often, when returning to a sitting position, the patient re-emerges a feeling of dizziness and nystagmus of lesser intensity and opposite direction. Such a test is considered positive and confirms the diagnosis of BPPV. If the test is negative, then a study is performed with the head turned to the other side.

In order to notice nystagmus during the test, it is recommended to use special Frenzel (or Blessing) glasses. These are glasses with a high degree of magnification, which allow to exclude the influence of arbitrary fixation of the patient's gaze. For the same purpose, a video nystagmograph or infrared eye movement recording can be used.

It should be borne in mind that when the Dix-Hallpike test is repeated, the severity of dizziness and nystagmus will be less, that is, the symptoms seem to be depleted.

Treatment

Current approaches to the treatment of BPPV are mostly non-pharmacological. Just 20 years ago it was different: the main treatment was medications reducing dizziness. When the mechanism of the development of the disease became known to scientists, the approach to treatment also changed. Free-floating crystals cannot be dissolved or immobilized with the help of medicines. That is why the leading role today belongs to non-drug methods. What are they?

These are the so-called positional maneuvers, that is, a series of successive changes in the position of the head and torso, with the help of which they try to drive the crystals into such a zone of the vestibular apparatus, from where they can no longer move (the sac zone), which means they will not provoke dizziness. During such maneuvers, attacks of BPPV may occur. Some maneuvers can be carried out independently, while others can be performed only under the supervision of a doctor.

The following positional maneuvers are currently considered the most common and effective:

• Brandt-Daroff maneuver. It can be carried out without the supervision of medical personnel. In the morning, immediately after sleep, a person needs to sit on the bed, dangling his legs. Then you need to quickly take a horizontal position on one side, slightly bending your legs. The head must be turned 45 ° up and lie in this position for 30 seconds. After - again take a sitting position. If a typical attack of BPPV occurs, then in this position it is necessary to wait for the dizziness to stop and only then sit down. Similar actions are then performed on the other side. Next, you need to repeat everything 5 times, that is, 5 times on one side and 5 times on the other. If dizziness does not occur during the maneuver, the next time the maneuver is performed the next morning. If an attack of dizziness still happened, then you need to repeat the maneuver in the daytime and in the evening;
• the Semont maneuver. Its implementation requires the control of medical personnel, since pronounced vegetative reactions may occur in the form of nausea, vomiting, and transient cardiac arrhythmias. The maneuver is carried out as follows: the patient sits on the couch, dangling his legs. The head turns 45° to the healthy side. The head is fixed by the doctor in this position with his hands and the patient is laid on the couch on his side on the affected side (the head, thus, turns slightly up). In this position, he should stay for 1-2 minutes. Then, keeping the same fixed position of the head, the patient quickly returns to the initial sitting position and immediately lies down on the other side. Since the head did not change its position, when laid on the other side, the face turns down. In this position, you need to linger for another 1-2 minutes. And then the patient returns to the starting position. Such sudden movements usually cause severe dizziness and vegetative reactions in the patient, so the attitude towards this method physicians have a double opinion: some find it too aggressive and prefer to replace it with more gentle maneuvers, while others, agreeing with its severity for the patient, are the most effective (especially in severe cases of BPPV);
• Epley maneuver. This maneuver is also desirable to carry out under the supervision of a physician. The patient sits down on the couch and turns his head to the affected side at an angle of 45 °. The doctor fixes the head with his hands in this position and puts the patient on his back while tilting the head back (as in the Dix-Hallpike test). Wait 30-60 seconds, then turn the head to the opposite side to the healthy ear and then turn the torso to the side. The head is turned upside down. And again wait 30-60 seconds. After that, the patient can take the initial sitting position;
• Lempert maneuver. It is similar in technique to the Epley maneuver. In this case, after turning the patient's torso on its side, and the head with a healthy ear down, continue to rotate the torso. That is, then the patient takes a position lying on his stomach with his nose down, and then on his sore side with his sore ear down. And at the end of the maneuver, the patient again sits down in the starting position. As a result of all these movements, a person, as it were, rotates around an axis. After the Lempert maneuver, it is necessary to limit the inclinations of the torso in the process of life and on the first day to sleep with the head elevated by 45°-60°.

In addition to the basic maneuvers, there are also various modifications of them. In general, with the correct conduct of positional gymnastics, the effect occurs after a few sessions, that is, only a few days of such therapy are needed, and BPPV will recede.

Drug treatment of BPPV today consists in the use of:

• vestibulolytic drugs (Betahistine, Vestibo, Betaserk and others);
• antihistamines (Dramina, motion sickness tablets);
• vasodilators (Cinnarizine);
• herbal nootropics (Ginkgo biloba extract, Bilobil, Tanakan);
• antiemetic drugs (Metoclopramide, Cerucal).

All these drugs are recommended for use in the acute period of severe BPPV attacks (accompanied by severe dizziness with vomiting). Then it is recommended to resort to positional maneuvers. Some doctors, on the contrary, talk about the unjustified use medicines in BPPV, citing the inhibition of their own mechanisms for compensating for vestibular disorders, as well as a decrease in the effect of positional maneuvers while taking medication. evidence-based medicine does not yet provide reliable data on the use of drugs in BPPV.

As a fixing, so to speak, therapy, a complex of vestibular exercises is used. Their essence is to perform a series of movements with the eyes, head and torso in those positions in which dizziness occurs. This leads to the stabilization of the vestibular apparatus, to an increase in its endurance, and to an improvement in balance. In the long term, this leads to a decrease in the intensity of symptoms of BPPV with a relapse of the disease.

Sometimes spontaneous disappearance of symptoms of BPPV is possible. Most likely, these cases are associated with the independent entry of crystals into the “silent” vestibular zone during normal head movements or with their resorption.

In 0.5-2% of cases of BPPV, positional gymnastics has no effect. In such cases, surgical removal of the problem is possible. Surgical treatment can be done in various ways:

• selective transection of vestibular nerve fibers;
• filling of the semicircular canal (then the crystals simply have nowhere to "swim");
• destruction of the vestibular apparatus with a laser or its complete removal from the affected side.

Many physicians also treat surgical methods of treatment in two ways. After all, these are operations with irreversible consequences. Restore cut nerve fibers or the entire vestibular apparatus after destruction and, moreover, removal is simply impossible.

As you can see, BPPV is an unpredictable disease of the inner ear, the attacks of which usually take a person by surprise. Due to sudden and severe dizziness, sometimes accompanied by nausea and vomiting, the sick person becomes afraid of possible causes of his condition. Therefore, when such symptoms appear, it is necessary to consult a doctor as soon as possible so as not to miss other more dangerous diseases. The doctor will dispel all doubts about the symptoms that have arisen and explain how to overcome the disease. BPPV is a safe disease, if I may say so, because it is not fraught with any complications, and even more so, it is not life-threatening. The prognosis for recovery is almost always favorable, and in most cases only the performance of positional maneuvers is required for the disappearance of all unpleasant symptoms.

Ph.D. A. L. Guseva reads a report on the topic "Benign paroxysmal positional vertigo: features of diagnosis and treatment":

Clinic of Professor Kinzersky, informative video about benign paroxysmal positional vertigo:

Vertigo attacks of vestibular origin, the provoking factor for which is a change in the position of the head and body, are called "benign paroxysmal positional vertigo." It is called benign because it is based on a mechanical nature, does not cause serious complications and disappears as suddenly as it appeared. This pathology is quite common. According to different authors, it accounts for 3 to 50% of all peripheral vestibular syndromes.

Causes and mechanisms of development

The occurrence of BPPV can be associated with various pathological conditions:

• operations on the structures of the inner ear;
• taking ototoxic antibiotics;
• migraine;
• spasm of the labyrinthine artery in autonomic disorders, etc.

However, in more than half of the cases, the cause of the disease cannot be established (idiopathic form).

The disease is based on the pathology of the inner ear - the destruction of the otolithic membrane, the mechanism of which remains unclear. At the same time, freely moving particles are formed in the vestibule of the labyrinth, which can be located in the smooth part of the semicircular canals or be fixed in the ampulla of one of them. They have a certain mass and density. Being in the endolymph, the particles tend to sediment. This process is very slow. Their maximum precipitation occurs during a night's sleep, when they form a clot that has a greater mass than each particle individually. It is his movement as a result of a change in body position after waking up that causes characteristic symptoms.

During the day, these particles are again dispersed and their mass is no longer sufficient for the hydrostatic changes in the endolymph that were observed initially. Therefore, with the repetition of inclinations, the severity of seizures weakens.

Symptoms

The main symptom of BPPV is recurrent attacks of sudden vestibular vertigo. It is felt by the patient as the rotation of objects around him and is often accompanied by nausea, vomiting. Most often, such attacks occur in the morning after waking up and getting out of bed or when turning in bed at night. Bending down and throwing the head back can also provoke dizziness.

A distinctive feature of dizziness is considered to be high intensity and duration up to 1 minute. The attack passes faster if the patient quickly returns to its original position. In some patients, the attack causes significant anxiety, which leads to throwing with a sharp change in body position in space, which further aggravates the situation and provokes repeated attacks. Moreover, people who are ill for a long time know what position causes dizziness in them, they try to move and turn slowly.

Along with typical bouts of dizziness, a person develops a specific positional nystagmus (oscillatory eye movements of an involuntary nature). It is detected by a specialist during an attack of dizziness. Its direction may be different. It is due to the localization of the pathological process. More often, this pathology occurs when the posterior semicircular canal is damaged (in this case, it is directed towards the ground), but it is also possible to involve other canals in the pathological process - the anterior and horizontal. In some cases, pathology occurs with the involvement of several channels in the pathological process on one or both sides.

A characteristic feature of the clinical picture of BPPV is the complete absence of other otological and neurological symptoms.

Sometimes in such patients disorders of the balance function are detected. However, this is not constant sign illness. It usually occurs during its long existence in combination with other causes that disrupt the functioning of the vestibular apparatus.

Diagnostics

The diagnosis of BPPV may be suspected by the physician based on the nature and timing of the onset of attacks, the history of the disease in the absence of other neurological and otological symptoms, and normal hearing. To confirm it, specific tests are carried out.

The most common among them is the Dix-Hallpike positional test. Its essence is as follows:

• before performing the test, the doctor must warn the subject of the high probability of developing characteristic symptoms and convinces of the safety and reversibility of this condition;
• at the beginning of the study, the patient is in a sitting position (on the couch), while the head is turned to the side (left or right) by 45 degrees;
• for its implementation, the specialist fixes the patient's head with both hands and quickly moves him from the starting position to the back, so that the head hangs slightly over the edge of the couch;
• if the test with turning the head in one direction gives a negative answer, then it must be repeated with a turn in the other direction.

The test results are evaluated according to the subjective sensations of the patient and the occurrence of nystagmus. After the tilt, some time passes before its manifestation. This is the so-called latent period. With the defeat of the posterior and anterior semicircular canals, it lasts no more than 3-4 seconds, with the involvement of the horizontal - 1-2 seconds. The total duration of this symptom ranges from 40 seconds to 1-2 minutes.

When the patient returns to the starting position, one can often observe a less pronounced reverse nystagmus directed in the opposite direction. When the test is repeated, the symptoms of the disease are less pronounced.

From instrumental research methods based on the registration of nystagmus are used. In this case, devices (glasses with special lenses) are used that can not only increase the possibility of observing nystagmus, but also eliminate gaze fixation. After all, it is the latter with DPPG that is able to suppress nystagmus.

With high accuracy, nystagmus can be recorded using video-oculography diagnostic systems with the possibility of mathematical processing of eye movements.

Nystagmus and positional vertigo can be a manifestation of not only BPPV, but also other pathological conditions with which differential diagnosis must be carried out:

• pathology of the posterior cranial fossa (characterized by various neurological symptoms, a pronounced balance disorder and nystagmus of central origin, which is not suppressed and is not depleted for a long time);
• vertebrobasilar insufficiency, etc.

Patient management

Therapeutic measures for BPPV are aimed at eliminating unpleasant symptoms, namely, stopping attacks of dizziness as soon as possible.

Currently, the main method of treating BPPV is considered to be therapeutic maneuvers, which involve the regular performance of certain exercises by a person independently or under the supervision of a specialist. The most famous among them are:

• Brandt-Daroff method (performed independently; in the morning immediately after sleep, the person is invited to sit in the center of the bed, then turn his head to the side at an angle of 45 degrees and lie alternately on the right and left side, lingering in each position for 30 seconds; the tilt should be repeated for 5 once on each side; in case of dizziness in one of the positions, the slopes are repeated day and evening);
• Semont's maneuver (requires the direct participation of a doctor; its essence lies in the rapid movement of the patient from one side to another, in which significant dizziness can occur with autonomic disorders in the form of nausea and vomiting);
• Epley maneuver (used for pathology of the posterior semicircular canal; carried out under the supervision of a specialist in compliance with a clear trajectory without a quick change of position);
• Lempert's maneuver (effective in lesions of the horizontal semicircular canal; also requires the presence and assistance of a doctor).

In the period after performing such exercises, the patient is recommended to observe the mode of limiting inclinations, and on the first day - and special position during a night's sleep (with a raised head end).

The duration of such treatment is determined individually, taking into account its tolerability and effectiveness. The latter depends on:

• from the ability to accurately move the patient's head in the plane of the affected canal;
• his age;
• the presence of concomitant pathology (for example, dorsopathy).

Currently, in order to achieve high accuracy in carrying out maneuvers, special electronic stands have been created that allow you to completely fix the patient and move him in the desired plane.

It should be noted that therapeutic maneuvers carried out jointly with a specialist give better results. Their effectiveness reaches 95%, while self-execution of exercises allows you to succeed only in 60% of cases.

With the ineffectiveness of such treatment, patients are recommended surgical intervention, the essence of which is to seal the affected channels. In rare cases, more traumatic methods (labyrinthectomy or laser destruction of the labyrinth) can be used.

Drug therapy to achieve this goal is practically not used due to low efficiency. However, with high vegetative sensitivity, such persons may be recommended to take betahistine for the period of medical manipulations.

Which doctor to contact

The treatment of this pathology is carried out by an otorhinolaryngologist. For differential diagnosis and finding out the causes of the disease, additional observation by a neurologist is usually required. This specialist can recommend for additional examination various methods– MRI or CT of the brain, EEG and others.