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Read ours please Game of the birthday Return to the index. Last modified of the page: Of February the 11 of 2006

Korean version Of the Spanish Of the Version

Treatment Of the Diagnosis Of the Causes

About the benign positional vertigo of Paroxysmal (BPPV) the vertigos think generally to be due to the ruin that has gathered within a piece of the internal oido one.  This ruin can be thought about  as the "ear oscillates", although the formal name is "otoconia". The rocks of the ear are small crystals of calcium carbonate derived from a structure in the called ear "utricle" (figure1). Whereas saccule also contains otoconia, they cannot emigrate in the system of the channel. Utricle could have been damaged by the injury in the head, the infection, or the other disorder of the internal oido one, or could have degenerated due to age outpost. Otoconia normally appears to have a slow volume of sales. They dissolve probably naturally as well as actively reabsorbados by the "dark cells" of the labyrinth (Lim, 1973, 1984), that is adjacent to utricle and the crest, although this idea is not accepted by all (it see to Zucca, to 1998, and Buckingham, 1999).

BPPV is a common cause of the vertigos. Near 20% of all the vertigos it is due to BPPV. Whereas BPPV can happen in children (Uneri and Turkdogan, 2003), the more old you are, the more probable is that their vertigos are due to BPPV. Near 50% of all the vertigos in older people he is due to BPPV. In a recent study, 9% of a group of old urban of the house were found to have undiagnosed BPPV (Oghalai ET al., 2000).

The BPPV symptoms include vertigos or vertigo, I am annoying, imbalance, and nausea. The activities that bring in symptoms will vary between people, but symptoms are precipitated almost always by a change of the position of the head with respect to gravity. Leaving the bed or rolling on in bed is common movements of the "problem". Because people with BPPV often feel that been annoying and unstable when their heads incline again to they watch for above, sometimes BPPV is called "superior vertigo of the shelf." The women with BPPV can find that the use of the bowls of source of the champú in rooms of the beauty brings in symptoms. An intermittent pattern is common. BPPV can be in favor present of some weeks, then to stop, later becomes again.

Suplemental material in the CD of the site: Animation of otoconia that is displaced in the later channel


The cause commonest of BPPV in people under age 50 is injury in the head. There is also an association with jaqueca (Ishiyama ET the a, 2000). In older people, the cause commonest is degeneration of the system to vestibular of the internal oido one. BPPV much more gets to be common with age that advances (Froeling ET the a, 1991). By half of all the cases, BPPV is called "idiopathic," that average it happens for no known reason. The virus that affects the ear as those that cause the neuritis to vestibular, movements of smaller importance such as those than imply previous syndrome inferior of the cerebelosa artery (AICA)", and the disease of Meniere is significant but unusual causes. BPPV follows the surgery once in a while, where the cause feels to be a combination of a prolonged period of the supina positioning, or the trauma of the ear when the surgery is to the internal oido one (Attacks ET the a the 2001). BPPV is also field common in the people who have dealt with the ototóxicas medications such as gentamicin (black ET the a, 2004). Other causes of positional symptoms are discussed here.



His doctor can make the diagnosis based on his history, the results in the physical examinación, and the results of auditory tests vestibulares and. Often, the diagnosis can be made with single history and the physical examinación. The figure to the right illustrates test DIX-Hallpike. In this test, they bring a person to seat to a supina position, with the given return 45 degrees to side and extended head near 20 degrees the other way around. The positive tests a DIX-Hallpike consist of an explosion of nistagma (jumping of the eyes). The eyes jump as well as twist upwards so that the superior part of the eye jumps down towards the lateral one. Chasque to see a film of nystagmu s of BPPV. here (direct transference of 13 megohms). The test can be made more sensible having the patient eyeglasses of Frenzel of the wearing down or the glasses video. Most of the doctors who specialize in seeing navigated patients they have these in its office.

With respect to history, the dominant observation is that the vertigos are driven lying down, or in rolling on in bed. Most of the other conditions that cause that the positional vertigos obtain worse in being unemployed rather who to lie down (e.g. hypotension orthostatic). There are some rare conditions that they have symptoms that are resembled BPPV. The patients with certain types of central vertigo such as ataxias to spinocerebellar can have "bed rotate" and prefer to the dream supported for above in bed (Jen ET the a, 1998). These conditions can be detected generally in a careful neurological examinación and also they are accompanied generally by familiar antecedents of other people with similar symptoms.

Electronystagmography (ENGLISH) that proves can be necessary to look for nistagma characteristic (jumping of the eyes) induced by test DIX-Hallpike. He has demanded himself that BPPV accompanied by unilateral lateral paralysis of the channel is suggestive of a vascular etiología (Kim ET the a, 1999). For the diagnosis of BPPV with the laboratory tests, it is important to test ENGLISH to do by a laboratory that can measure the heaves of the eye. An exploration of the projection of image of magnetic resonance(MRI) will be made if a tumor is suspected the movement or brain. A rotating test of the chair can be used for the difficult problems of diagnosis. He is (5%) possible but infrequent to have BPPV in both ears (bilateral BPPV).


BPPV has been described often like "one same-limiting" because the symptoms often collapse or disappear in the term of 2 months of the beginning (imai ET the a, 2005). BPPV is not intrinsic dangerous for the life. One can choose certainly as soon as to wait for it towards outside.


No active treatment (wait/see):

If you decide to wait for it towards outside, certain modifications in their daily activities can be necessary to face their vertigos. Use two or more pads at night. Avoid to sleep in "badly" the side. In the morning, it levántese slowly and it siéntese in the edge of the bed by a minute. Avoid to bend down to take things, and to extend the head, for example to obtain something of a cabinet. Have well-taken care of when in the office of the dentist, the room of the beauty when lying behind having a washed hair, when participating in activities of the sports and when you are lying completely in your posteriora part.

The symptoms tend to encerar and to diminish. The medications of the movement disease are sometimes beneficial in controlling associated nausea to rarely beneficial BPPV but they are of another way.

Then the BPPV tin lasts for much more of length of 2 months, in our opinion, is better to treat the one than activelyand takes control rather of him who taking the approach from wait/see.

TREATMENT OF THE BPPV OFFICE: The maneuvers of Epley and Semont

There are two treatments of BPPV that are made generally in the office of the doctor. Both treatments are very effective, with rough a tariff of the treatment of 80%, according to a study of Herdman and others (1993). If his doctor is desconocedor with these treatments, you can find a list of clinical good informed into the association to vestibular of the disorders (PROHIBITION).

The maneuvers, named after their inventors, think to move the ruin or the "ear oscillates" of the sensible piece of the ear (later channel) to a less sensible location. Each maneuver takes near 15 minutes to finish. The maneuver of Semont (also called the maneuver "liberatory") implies a procedure by which they move quickly to the patient from the lie in a side to the lie in the other (Levrat ET the a, 2003). She is one maneuvers energetic that is not favored at the moment in the United States, but are effective 90% after 4 sessions of the treatment. In our opinion, he is equivalent to the maneuver of Epley as the positioning of the head is very similar, only omitting ' C ' of the figure to the right.

The maneuver of Epley also is called placing again of the particle, procedure that it again places of canalith, and maneuvers liberatory modified. One acquires knowledge in picture 2. Chasque here for a low animation of the width of band. It implies the sequential movement of the head in four positions, remaining in each rough position by 30 seconds. The tariff of the repetition for BPPV after these maneuvers are near 30 percents in a year, and some cases a second treatment can be necessary.

Variants: Whereas the use of the lawyer of some authors of the vibration in the maneuver of Epley, we has not found this useful one in a study of our patients (Hain ET the a, 2000). The use of a antivomiting one before the maneuver can be beneficial if nausea is anticipated. Some authors suggest it position ' D ' in the figure is not necessary (e.g. (Cohen ET the a. 1999; Cohen ET to. 2004). In our opinion, this is an error as modeling BPPV mathematician suggests it position ' D ' is the most important position (landowners ET the a, 2004).

When making the maneuver of Epley, advises the precaution must the neurological symptoms (for example, visual weakness, entumecimiento, changes with exception of the vertigo) happen. Such symptoms are caused once in a while by the compression of the vertebrales arteries (Sakaguchi ET the a, 2003), and if one persists, a movement could happen. If the exercises are being made without the medical supervision, we advised to stop the exercises and to consult a doctor. If the exercises are being supervised, since the diagnosis of BPPV is established, in most of the cases we modified the maneuver to rather obtain the positions with the movements of the body that the main movements.

After anyone of these maneuvers, you must be prepared to down follow the instructions, that go that they reduce the occasion that the ruin could fall again within the sensible back piece of the ear.

The maneuver of "Gans". This is a small used maneuver of the treatment, call the "maneuver of Gans by him is the inventor (R. Gans, Ph.D.), who is a hybrid between the maneuvers of Epley and Semont. It incorporates the main directions to the gravity of "B" and of "D" in the figure of Epley it arrives, using the positions of the body of the maneuver of Semont. There is too much little experience published with this maneuver to say if it is as effective as the Epley/Semont but we suspected that it has the same effectiveness, because it uses the same primary positions.

Suplemental material in the CD of the site: Animation of the maneuver of Epley.

Observe that this maneuver is done more quickly in the animation that in the clinic. One generally gives a term of 30 seconds between the positions.

Suplemental material in the CD of the site: Film of the maneuver of Semont


1. The delay by 10 minutes after the maneuver is made before going to house. This one must avoid "fast returns," or brief explosions of the vertigo whereas the ruin is placed again immediately after the maneuver. Home is not conducted.

2. Dream semi-recumbent for the two next nights. This halfway means dream with its flat and vertical head between being (an angle of 45 degrees). This is made more easily possible using a chair of recliner or using the pads ready in a sofa (it see picture 3). During the day, it tries to maintain his head vertical. You do not have to go to the peluquero or the dentist. No exercise that requires the main movement. When the shaved one of the men underneath its chins, they must double its bodies ahead to maintain its head vertical. If they require eyedrops, attempt to behind put them inside without the inclination of the head. Champú only underneath the shower. Some authors suggest are necessary no special positions sleeping (Cohen, 2004; Massoud and Ireland, 1996). We thought that there is a certain value of making these things.

3. For at least one week, it avoids to cause the primary positions that could bring ignited BPPV again.

Be careful to avoid the head-extended position, in which you are lying in your posteriora part, specially with its head given return towards the affected side. This means is cautious in the room of the beauty, the office of the dentist, and whereas it experiences the surgery of smaller importance. Try  to remain as vertical as it is possible. The exercises for the backache are due to stop by one week. No "seat-raises" must be made for at least one week and no swimming of the "drag". (the movement of the chest is ACCEPTABLE.) Also it avoids the positions distant head-advantages such as it could happen in certain exercises (it is to say touching the toes). It does not begin to immediately do the exercises of Brandt-Daroff or 2 days after the maneuver of Epley or Semont, unless it is commanded specifically of another way by his supplier of the medical care.

4. In one week after the treatment, it póngase in the position that to him does been annoying generally. Coloqúese cautiously and under conditions in which you cannot fall or hurt yourself. Let to his doctor know you you did it.

Commentary: Massoud and Ireland (1996) indicated that the instructions post-treatment were not necessary. Whereas we respected these authors, in this writing (2002), still we felt it more better possible to follow the procedure recommended by Epley.


They have disclosed than 394 patients in studies more controlled. The medium answer in treated patients was 81%, compared to 37,% in placebo or subjects untreated. See here for the details.


These maneuvers are effective in near 80% of patients with BPPV. If you are between the other 20 percents,  his doctor can wish him to come with the exercises of Brandt-Daroff, according to the described thing down. If a maneuver works but the symptoms are repeated or the answer is only partial (near 40% of the time according to Smouha, 1997), another test of the maneuver could be advised. The exercises of the "habituación" are also sometimes useful in the situation where the rest of the maneuvers has been tried (Epley, Semont, Brandt-Daroff) -- essentially these consist of one more a more intense and prolonged series of positional exercises. When all the maneuvers have been tried, the diagnosis is clear, and the symptoms continue being intolerable, surgical management (later channel that covers) can be offered.

BPPV is often repeated. Near 1/3 of patients it has a repetition in the first year after the treatment, and by five years, on half of all the patients has a repetition (Hain ET the a, 2000; Nunez ET to; 2000; Sakaida ET to, 2003). If BPPV is repeated, in our practice we retired generally with one of the maneuvers above. Whereas the daily use of the exercises of Brandt-Daroff would look like sensible, we did not find it to prevent the repetition (Helminski ET the a, 2005).

In some people, the positional vertigo can be eliminated but the imbalance persists. In these people it can be reasonable to undertake a course of the rehabilitation to vestibular generic, as they can immovable necessity compensate for a mass to utricular changing or a component of the persistent vertigo caused by cupulolithiasis. The rehabilitation to vestibular conventional has certain effectiveness, uniforms without specific maneuvers. (Angeli, Hawley ET to. 2003; Fujino ET to, 1994))



Chasque here for a low animation of the width of band

The exercises of Brandt-Daroff are a method to treat BPPV, used generally when the treatment of the office fails. They are successful in 95% of cases but they are more arduous than the treatments of the office. These exercises can last that the other maneuvers -- the rate of answer in one week is near 25% (Radke ET the a, 1999). These exercises are made in three systems by the day by two weeks. In each system, one makes the maneuver according to demonstrated the five times.

1 repetition = maneuver done to each side alternadamente (takings 2 minutes)

Schedule suggested for the exercises of Brandt-Daroff
Time Exercise Duration
Tomorrow 5 repetitions 10 minutes
Noon 5 repetitions 10 minutes
Late 5 repetitions 10 minutes

Begin to seat vertically (position 1). Then it muévase in the side-lie position (position 2), with the head fished with cane upwards around halfway. A way easy to remember this is to imagine somebody being unemployed of near 6 feet in front of you, and right subsistence watching of its head always. Remain in the position of side-lie by 30 seconds, or until the vertigos one collapses if this is longer, later goes again to the position that feels (position 3). Remain there by 30 seconds, and later it goes alongside opposite (position 4) and follows the same routine.

These exercises are due to make by two weeks, three times per day, or three weeks, twice per day. This adds altogether up to 52 systems. In most of the people, the complete relevación of symptoms is obtained after 30 systems, or near 10 days. In approximately 30 percents of patients, BPPV will be repeated in the term of a year. If BPPV is repeated, you can wish to add an exercise 10-make a draft to your daily routine (Amin ET the a, 1999). The Brandt-Daroff exercises as well as the Semont and the maneuvers of Epley are compared in an article by Brandt (1994), enumerated in the section of the reference.

When making the maneuver of Brandt-Daroff, advises the precaution must the neurological symptoms (it is to say visual weakness, entumecimiento, changes with exception of the vertigo) happen. Such symptoms are caused once in a while by the compression of the vertebrales arteries (Sakaguchi ET the a, 2003). In this situation we advised not to come with the exercises and consulting material of physician.Supplemental in the CD of the site: Animation of the exercises of Brandt-Daroff. Observe that this maneuver of the treatment is done more quickly in the animation that in real use. One generally gives a term of 30 seconds between the positions.

Suplemental material in the CD of the site: Film of the exercises of Brandt-Daroff

We offer a homemade treatment DVD that illustrates the exercises of Brandt-Daroff.


The maneuvers of Epley and/or Semont according to the described thing above can be done in the country (Furman and Hain, 2004). For example, skirts a protocol of Epley of self-treatment. We can recommend the home-Epley to our patients who have a clear diagnosis. This procedure still more looks like to be effective that the procedure of the in-office, perhaps because every night by one week is repeated.

There are, nevertheless, several possible problems that they can appear. If the diagnosis of BPPV has not been confirmed, one can try to deal another condition (as a tumor or a movement of brain) with positional exercises -- this is little probable to be guessed right and can delay the appropriate treatment. A second problem is that the home-Epley requires the knowledge of "badly" the side. Sometimes this can be difficult to establish. The complications such as conversion to another channel (it see down) can happen during the maneuver of Epley, that are handled better in the office of a doctor who in the country. Finally, once in a while during the maneuver of Epley the neurological symptoms are caused due to the compression of the vertebrales arteries. In our opinion, he is safer to have the first Epley made in an office of the doctors in where the appropriate action can be taken in this eventuality.

We offer a homemade treatment DVD that illustrates the homemade exercises of Epley.



If the described exercises above are ineffective in symptoms that they control, the symptoms have persisted by a longer year or,  and the diagnosis is very clear, a surgical procedure called "later channel that covers" can be recommended. Channel that covers blocks more of the function of the later channel without affecting the functions of the other channels or the pieces of the ear. This procedure raises a risk to the small hearing, but he is effective in near 90% of the individuals that have not had any answer to any other treatment. Near 1 percent of our patients of BPPV it only makes possible east procedure do.  It has been procured and the surgery has been failed is not due to consider until the three maneuvers/exercises (Epley office, Semont office, homemade Epley). See the article of Parnes (1990, 1996) in the references for more information.

There are several alternative surgeries. The Dr Gacek (Syracuse, New York) has written extensively on the singular section of the nerve. The Dr Anthony (Houston, Roofing tiles), pleads to cover later attended laser of the channel. It looks like us that these procedures, that require unusual amounts of surgical ability, have little advantage on a conventional channel that covers procedure. Of course, surgery is always recommendable when gliding to select to a surgeon who has had so wide a experience as possible.Complications is rare (Rizvi and Gauthier, 2002)

There are several surgical procedures that we felt we are desaconsejables for the individual with insurmountable BPPV.  The section to vestibular of the nerve, whereas he is effective, eliminates more of the system to vestibular normal that necessary. Similar, the treatment transtympanic of gentamicin looks like generally inadequate. Labyrinthectomy and sacculotomy are also both generally inadequate due to  the reduction or auditory loss the ear waited for with these procedures.


Lateral channel BPPV, previous channel BPPV, Cupulolithiasis, Vestibulolithiasis, patterns of Multi-channel

There are several rarer variants of BPPV than it can happen spontaneously as well as after the maneuvers of Brandt-Daroff or the maneuvers of Epley/Semont. They think mainly to be caused by the migration of the otoconial ruin in the channels with exception of the later channel, of the previous or lateral channel. It is also possible that something is due to other conditions such as brainstem or cerebeloso damage, but the clinical experience suggests this one is very rare.

There are at the moment data no disclosed as far as the frequency and the degree of these syndromes after procedures of the treatment. It is the estimation of the author that happens in rough 5% of the maneuvers of Epley and near 10% of the time after the exercises of Brandt-Daroff. In almost all the cases, with the exception of the cupulolithiasis, these variants of the following resolution of the maneuvers of BPPV within one week without no special treatment, but when they do not do it, there are procedures available to treat them.

In clinical practice, abnormal BPPV that appears spontaneously first deals with maneuvers like typical BPPV, and the special treatments as skirted down they enter only after lack of the treatment. When abnormal BPPV follows the Epley, Semont or Brandt-Daroff maneuvers, the specific exercises is begun generally as soon as verifies the diagnosis. In the patients in those who the treatment of the abnormal exercise of BPPV fault, in situations where the beginning of diagnosis is the test spontaneous, specially additional as exploration of MRI can be indicated. The reason of this is to look for other types of positional vertigo.

Lateral channel BPPV is the abnormal variant commonest of BPPV, accounting stops near 3-12 percent of cases (Korres ET the a, 2002; Hornibrook 2004). Many cases are seen as a result of a maneuver of Epley. It is diagnosed by nistagma horizontal that changes the direction according to the ear that is down. More detail on lateral channel BPPV as well as an illustration of a homemade exercise can be found here

Previous channel BPPV is also rare, and a recent study suggested considers near 2% of cases of BPPV (Korres ET the a, 2002). Downbeating and in taking position DIX-Hallpike is diagnosed by nistagma positional with the components of the torsional movement, or nistagma that is upbeating and torsional when seating for above of the DIX-Hallpike. There is a number of diverse suggestions in Literature on the direction of the torsional fast phase in previous channel BPPV. In our opinion, nistagma during the DIX-Hallpike to a side is more likely due to the excitation of the previous channel in the opposite side. This must cause nistagma downbeating as well as nistagma torsional with a express-phase towards the disturbado ear. Thus the direction of the torsional component during the down-phase of the DIX-Hallpike says to him which is badly heard. Previous channel BPPV can be caused of the ear opposed next to maneuver DIX-Hallpike -- it is to say if you obtain been annoying to the right, the ear of the problem could be the left. Some authors have suggested because the previous channels are oriented so that the pieces are near the saggital plane, previous channel BPPV can be caused with a maneuver DIX-Hallpike to any side as well as in the position that hangs of the "head" (Bertholon ET the a, 2002). We have found some patients who have ONLY nistagma in the position head-that hangs. Nistagma upbeating in the sitting can be very persistent whereas the ruin places in cupula of the previous channel. Previous channel BPPV is probably rare because the previous channel is normally the highest piece of the ear. The ruin would tend naturally to fall of later half of the previous channel. Of the geometry of the ear, it would probably look like that previous channel BPPV could be once in a while like complication of the maneuver of Epley.

The ruin could also be located temporarily in the common area of the thigh, that it is the channel shared between the previous and later channel. If the ruin were present in cruse common, one counted on nistagma purely torsional. During down the phase of the DIX-Hallpike, when the ruin is falling the other way around towards ampulla, nistagma torsional it must beat far from badly heard. During the ascending phase of the DIX-Hallpike, when the ruin is moving towards the lobby, nistagma torsional it must beat towards badly heard.

In our clinic that fixed to Chicago, we have had most of the success in dealing previous channel BPPV with a "deep DIX-Hallpike". The idea is to invest the previous channel, it allows the ruin lowers to the "cover" of the channel, and later it allows that the lobby emigrates more far in common the then thigh and.

Cupulolithiasis is a condition in which the ruin sticks to cupula of a semicircular channel, rather that the loose being within the channel. Cupulolithiasis is not a complication of the treatment, but something of the BPPV phantom is part. The mechanical hypothesis is based on pathological results of deposits in cupula made by Schuknecht and the ruby in three patients who had BPPV during their lives (Schuknecht 1969; Schuknecht ET to. 1973). Moriarty and the colleagues found similar deposits in 28% of 566 temporary bones (Moriarty ET the a. 1992). Schuknecht needed that the hypothesis of the cupulolithiasis cannot explain characteristic the latency and generally explode the pattern of nistagma of BPPV as well as remissions (Schuknecht ET the a. 1973). Something, the cupulolithiasis must give rise nistagma constant. This pattern considers (Smouha ET sometimes the a. 1995). Cupulolithiasis could happen theoretically in any channel -- horizontal, previous or vertical, each one of which could have must have the pattern of nistagma positional. Some authors maintain that the hypotheses of the cupulolithiasis and the canalithiasis can be correct (Brandt ET the a. 1994). If the cupulolithiasis is suspected, it looks like logical to deal with or the Epley with the vibration, or alternatively, it uses the maneuver of Semont. There are studies of the no cupulolithiasis to indicate what strategy is most effective.

Vestibulolithiasis is a hypothetical condition in which the ruin is present in the lobby-side of cupula, rather that being in the side of the channel. For this theory, there is loose ruin, near but unattached to cupula of the later channel, possibly in the lobby or the short arm of the semicircular channel. The pathological studies of BPPV have found equal amounts rough of fixed ruin of any side of cupula (Moriarty ET the a. 1992), suggesting it loose ruin could also be found of any side. For the mechanism of the vestibulolithiasis, when the head moves, the stones or the other ruin could change of lobby position ampulla, or within ampulla, affecting cupula. Nistagma was hoped that this mechanism was resembled cupulolithiasis, having persistent, but with intermittency because the ruin is movable. The very small data are available as far as the frequency of this pattern, and there are data no available watching the treatment.

Patterns of Multi-channel. If the ruin can obtain in a channel, why does not have to be able to obtain in more than one? It is common to find small amounts of nistagma horizontal or nistagma downbeating contralateral in a person with later channel classic BPPV. Whereas other explanations are possible, most probable it is than there is ruin in shared channels. A Literature is becoming gradually on these situations (Bertholon ET the a, 2005).


The association to vestibular of the disorders (PROHIBITION) maintains a great and comprehensive list of the doctors who have indicated an ability in BPPV that treated. Éntrelos in contact with please finding a doctor who treats the premises.



Literature and mulltimedia that we recommended


Chasque here for the recent, but possibly less excellent references.

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