Common Diagnoses

Benign Paroxysmal Positional Vertigo (BPPV)

Benign paroxysmal positional vertigo, also known as positional vertigo, benign positional vertigo, canalithiasis, cupulolithiasis, and BPPV, is the most common cause of peripheral (inner ear) vertigo. It is characterized by brief spinning vertigo lasting several seconds to a few minutes, usually occurring with turning the head, tilting the head back or leaning forward. Individuals with BPPV often complain of symptoms with rolling over in bed, getting in or out of bed, as well as symptoms throughout the day with head movement. Usually, symptoms are worse with turning to the affected side. In addition to the intermittent spinning sensation with head movement, some patients will have persistent dizziness, or a lightheaded sensation throughout the day. Often, symptoms will spontaneously resolve with in a few days. However, many patients have symptoms that, if left untreated, will last for weeks to months.

BPPV is caused by free-floating crystals (otoliths) in the balance canals. Otoliths are tiny calcium carbonate crystals that normally are positioned in another part of the inner ear, known as the utricle. When otoliths get displaced into a balance canal, symptoms of BPPV occur. The problem can occur in older children and adults of any age, but there is an increased incidence with advanced age. BPPV is also more common after head trauma, and in diagnoses of Ménière's disease, vestibular neuritis, and migrainous dizziness.

BPPV can often be diagnosed on direct physical examination. Sometimes, specialized testing using VNG/ENG equipment is needed to confirm the diagnosis.

Relief from persistent symptoms for most patients can be achieved by treatment in the office using an Epley Maneuver, also known as canalith repositioning maneuver, to move the otoliths out of the balance canal. This treatment can be performed by a balance therapist or by a physician. Some patients with persistent dizziness and balance problems may require longer term Vestibular and Balance Therapy to resolve all of their symptoms. Rarely surgery may be required to treat BPPV.

Aging of Balance System

Proper balance function is dependent on a variety of factors that may be affected as an individual ages. For many people, the inner ear balance organ weakens with age. Also, the brain's processing of signals from the inner ear can be slower and less effective. Orthopedic issues that affect muscles and joints can adversely affect balance function, as can other medical problems that affect a person's ability to stay physically active. Necessary medications may also impact balance function. As there is no one problem that causes balance dysfunction in older people, it is important to have an appropriate assessment to determine the potential causes as well as ways to improve the balance function. Vestbular testing including VNG, rotary chair and posturography help identify causes of balance dysfunction in older patients. Vestibular rehabilitation therapy can significantly improve balance function and restore safety for a significant percentage of individuals suffering from balance disorders related to aging.

Vertigo of Central (brain) Origin

Central vertigo is a term used to describe vertigo arising from the central nervous system (CNS) and includes diseases affecting the brain and cranial nerves. Any of a number of diagnoses that affect the CNS, including stroke and ischemia (vertebrobasilar disease), multiple sclerosis, migrainous vertigo, infections of the brain, benign and malignant tumors of the brain, and acoustic neuromas may cause central vertigo. Patients with central causes of vertigo tend to have more lengthy periods of dizziness and vertigo that do not follow a specific pattern for a peripheral (inner ear) vertigo. They may also exhibit other neurological symptoms including headaches, and sensory or motor symptoms. A careful review of symptoms, physical examination, vestibular tests and radiology studies are used to identify central vertigo diagnoses. Results of vestibular testing including ENG/VNG, Rotary Chair Testing and Computerized Dynamic Posturography can often be used to help distinguish between central and peripheral vertigo causes.

Migrainous Dizziness

Migrainous dizziness and vertigo refers to symptoms of dizziness, lightheadedness, or spinning sensation that occur due to migraine. Patients with a history of migraines or a strong family history of migraines are more likely to experience migrainous dizziness. These symptoms can occur with associated headache symptoms, but can also present independent of the classic migraine picture. Migrainous dizziness and vertigo tends to persist for longer duration than is typically seen in inner ear disorders. Some patients may also experience other ear related symptoms including hearing loss and tinnitus. Interestingly, migrainous dizziness has been shown to have an increased frequency in patients with other inner ear disorders including BPPV and Ménière's disease. The understanding of migrainous dizziness and vertigo is relatively new and evolving. Currently, there is not a definitive test to diagnose the problem, although there is evidence that certain findings on VNG and Rotary Chair testing are specific to migrainous dizziness. Patients with migrainous dizziness should be evaluated and managed by a neurologist or neurotologist. Effective management can usually be achieved by treatment with suppressive migraine therapies and by following a migraine diet.

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