Benign paroxysmal positional dizziness

Benign paroxysmal positional vertigo is a disease of the vestibular apparatus characterized by sudden attacks of dizziness. Four words from the title carry the main essence of this problem: "benign" means the absence of consequences and the possibility of self-healing, "Paroxysmal" refers to the paroxysm of the disease, "positional" indicates the dependence on the position of the body in space, and "vertigo" is the main symptom. However, for apparent simplicity, many subtleties are hidden. All that concerns benign paroxysmal positional dizziness, you can learn about the basic information and subtleties of this disease after reading this article.

In general, dizziness is a very nonspecific symptom. Naviskidku can be called more than 100 diseases that can manifest themselves dizzy. But benign paroxysmal positional dizziness is inherent in some clinical features, due to which a correct diagnosis can be established already at the initial examination doctor.

Benign paroxysmal positional vertigo (DPPH) is considered a fairly common disease. The countries of Western Europe issue the following statistics: up to 8% of their population suffers from this ailment. The CIS countries, unfortunately, do not have reliable statistics on this problem, but they are unlikely to be significantly different from European ones. Up to 35% of all cases of vestibular vertigo can be associated with DPPH. The figures are impressive, are not they?

For the first time, PDPH was described by the Austrian otolaryngologist Robert Barani in 1921 with a young woman. And since then, the symptoms of BPHD have become a separate disease.

The causes and mechanism of the development of DPAH

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

The main part of the vestibular apparatus consists of three semicircular canals and two sacs. Semicircular canals are located almost at right angles to each other, which allows you to capture the movements of a person in all planes. The channels are filled with liquid and have an expansion - ampoule. In the ampoule is located gelatin-like substance of the cupula, which has a close connection with the receptors. The movements of the cupula along with the fluid flow inside the semicircular canals and create a sense of position in space for a person. The upper layer of the cupula can contain crystals of calcium bicarbonate - otoliths. Normally throughout life, otoliths are formed and then destroyed by natural aging of the body. The products of destruction are utilized by special cells. This situation corresponds to the norm.

Under certain conditions, the spent and obsolete otoliths are not destroyed and, in the form of crystals, float in the fluid of the semicircular canals. Of course, the appearance of additional objects in the semicircular canals 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 a zone under the action of gravity (usually a zone of pouches), then the dizziness disappears. The described changes are the main mechanism of the occurrence of RPAH.

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

• craniocerebral trauma (due to traumatic separation of otoliths);
• viral inflammation of the vestibular apparatus (viral labyrinthitis);
• Ménière's disease;
• surgical manipulation of the inner ear;
• taking ototoxic antibiotics of gentamicin series, intoxication with alcohol;
• spasm of the labyrinthine artery, which carries out the blood supply of the vestibular apparatus (for example, with migraine).

Symptoms

DPPG are characterized by specific clinical features, which are the basis for the diagnosis of this disease. So, RPGS is characterized by:

• sudden attacks of severe dizziness that occur only when the position of the body changes, that is, at rest, dizziness never appears. Most often, an attack provokes a transition from a horizontal position to a vertical position after a dream, turns in a bed in a dream. The leading role in this case belongs to the change in the position of the head, and not of the trunk;
• Dizziness can be felt like moving your own body in space in any plane, like rotating objects around, like a feeling of falling down or up, wiggling on the waves;
• the duration of a dizziness attack does not exceed 60 seconds;
• sometimes dizziness may be accompanied by nausea, vomiting, slow heart rate, diffuse sweating;
• Attack of dizziness accompanies nystagmus - oscillatory involuntary movements of eyeballs. Nystagmus can be horizontal or horizontal-rotational. As soon as dizziness stops, nystagmus disappears immediately;
• attacks of dizziness are always the same, never change their "clinical color are not accompanied by the appearance of other neurologic symptoms;
• Attacks are more pronounced in the morning and in the morning. Most likely, this is due to the dispersal of crystals in the fluid of semicircular canals with constant head movements. Crystals are broken into smaller particles in the first half of the day (motor activity significantly higher in the period of wakefulness than in the period of sleep), so in the second half the symptoms are almost not arise. During the sleep period, the crystals again "stick together leading to an increase in symptoms in the morning;
• When examined and carefully examined, other neurological problems are never found. There is no noise in the ears, no hearing impairment, no headache - no additional complaints;
• perhaps spontaneous improvement of the condition and the disappearance of attacks of dizziness. This is probably due to the self-dissolution of the detached crystals of calcium bicarbonate.

DPPG - this is often the lot of people older than 50 years. Perhaps by this time the natural processes of resorption of calcium bicarbonate crystals are slowing down, which is the reason for the more frequent occurrence of the disease at this age. According to statistics, the female sex suffers from DPPH 2 times more often than masculine.

Diagnostics

Clinical features of DPPH allow you to come close to the correct diagnosis already at the stage of questioning the patient. Clarifying the time of occurrence of dizziness, provoking factors, the duration of seizures, the absence of additional complaints - all this leads to thoughts about RPPG. However, it is necessary to obtain a more reliable confirmation. To this end, perform special tests, the most common and simple of which is the Dix-Hallpike test. The sample is carried out as follows.

The patient is seated on the couch. Then turn (do not tip!) The head in one direction (presumably, in the direction of the affected ear) by 45 °. The doctor seems to fix his head in this position and quickly puts the patient on his back, keeping the angle of the head. In this case, the patient's trunk should be placed in such a way that the head hangs slightly over the edge of the couch (that is, the head should be slightly thrown back). The doctor watches the patient's eyes (in anticipation of nystagmus) and simultaneously asks about a feeling of dizziness. In fact, the sample is a provocative test for a typical attack of DPPH, since it causes the crystals to shift in semicircular canals. In the case of the presence of RPAH, approximately 1-5 seconds after the patient is laid, nystagmus and typical dizziness occur. Then the patient is returned to the sitting position. Often, when returning to the sitting position, the patient repeatedly experiences a feeling of dizziness and nystagmus of a lesser intensity and opposite direction. Such a test is considered positive and confirms the diagnosis of DPPH. If the sample is negative, then conduct a study with a turn of the head in the opposite direction.

In order to notice the nystagmus during the test, it is recommended to use special glasses of Frenzel (or Blessing). These are spectacles with a large degree of magnification, which make it possible to exclude the effect of arbitrary fixation of the eyesight to patients. For the same purpose, a videoistagmograph or infrared eye movement recording can be used.

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

Treatment

Modern approaches to the treatment of ADHD are mainly non-drug. Only 20 years ago it was different: the main method of treatment were medications that reduce dizziness. When the mechanism of disease development became known to scientists, the approach to treatment changed. Being in free floating crystals with the help of medicines can not be dissolved or immobilized. That is why the predominant role today belongs to non-drug ways. What are they?

These are the so-called positional maneuvers, that is, a series of successive changes in the position of the head and trunk, with the help of which they try to drive crystals into a zone of the vestibular apparatus from which they can no longer move (the zone of the sacs), and, therefore, will not provoke dizziness. In the course of such maneuvers, the occurrence of seizures of DPAH is possible. Part of the maneuvers can be carried out independently, while others can be performed only under the supervision of a doctor.

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

• a maneuver of Brandt-Daroff.It can be conducted without the supervision of medical personnel. In the morning, right 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 should be rotated 45 ° upwards and lie in this position for 30 seconds. After - again, take a sitting position. If there is a typical attack of DPAH, then in this position, you should wait for the dizziness to stop and then sit down. Similar actions are then performed on the other side. Then 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 a dizziness attack does occur, then it is necessary to repeat the maneuver in the daytime and evening time;
• the maneuver of Demont.It requires monitoring of medical personnel, since it is possible to develop pronounced vegetative reactions in the form of nausea, vomiting and transient cardiac arrhythmias. The maneuver is as follows: the patient sits on the couch, his legs hanging. The head turns 45 ° to a healthy side. The head is fixed by the doctor in this position with hands and the patient is placed on the couch on his side on the sick side (the head, thus, turns slightly upwards). In this position, he should stay 1-2 minutes. Then, keeping the same fixed position of the head, the patient quickly returns to the initial sitting position and immediately fits on the other side. Since the head did not change its position, then when lying on the other side, the face is turned down. In this position, you need to stay another 1-2 minutes. And then the patient returns to the starting position. Such abrupt movements usually cause severe dizziness and vegetative reactions in the patient, so the attitude to this method is twofold: one finds it too aggressive and prefer to replace it with more gentle maneuvers, others, agreeing with its weight for the patient, the most effective (especially in severe cases DPPG);
• the maneuver of Epley.This maneuver is also desirable to carry out under the supervision of a doctor. The patient sits on the couch and turns his head to the sore side at an angle of 45 °. The doctor fixes the head with his hands in this position and puts the patient on his back with a simultaneous tilting of the head (as with a Dix-Hallpike sample). They wait 30-60 seconds, then turn their head to the opposite side to a healthy ear and then turn their torso on their sides. The head is turned with the ear down. And again they wait 30-60 seconds. After that, the patient can take the initial position while sitting;
• maneuver of Lempert.It is similar in technique to the conduct of the maneuver of Epley. In this case, after turning the patient's trunk to the side, and the head with a healthy ear down, the torso continues to rotate. That is, further the patient occupies a position lying on his stomach with his nose down, and then on the sick side with a sick ear down. And at the end of maneuver the patient again sits down in the starting position. As a result of all these movements, the person, as it were, rotates around the axis. After Lempert's maneuver, it is necessary to limit the torso slopes in the process of vital activity and in the first day to sleep with a head raised 45 ° -60 °.

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

Currently, medical treatment of DPPH consists of the following:

• vestibulolytic drugs (Betagistin, Vestibo, Betaserk and others);
• antihistamines (Dramina, pills for motion sickness);
• vasodilators (Cinnarizine);
• plant nootropics (extract of Ginkgo biloba, Bilobil, Tanakan);
• antiemetic drugs (Metoclopramide, Cerucal).

All these drugs are recommended to use in the acute period of severe attacks of DPPH (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 of medicines in RPPG, motivating it with oppression own mechanisms for compensating vestibular disorders, as well as reducing the effect of positional maneuvers on the background of medicines. Evidence-based medicine does not yet provide reliable data on the use of medicines in RPAS.

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

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

In, -2% of cases of DPPH positional gymnastics does not give effect. In such cases, surgical resolution of the problem is possible. Operative treatment can be carried out in various ways:

• selective transection of vestibular nerve fibers;
• sealing of the semicircular canal (then the crystals simply have nowhere to "swim");
• Destruction of the vestibular apparatus by means of a laser or complete removal of it from the affected side.

To surgical methods of treatment also many physicians are treated in two ways. After all, it's operations with irreversible consequences. To restore the cut nerve fibers or entire vestibular apparatus after destruction and, moreover, removal is simply impossible.

As you can see, RPG is an unpredictable disease of the inner ear, whose attacks usually catch a person by surprise. In connection with a sudden and severe dizziness, sometimes accompanied by nausea and vomiting, a person becomes ill with fear of possible causes of their condition. Therefore, when such symptoms appear, you should contact your doctor as soon as possible so that you do not miss other more dangerous diseases. The doctor will dispel all doubts about the symptoms and explain how to overcome the ailment. DPPG is a safe disease, if you can say so, because it is not fraught with any complications and certainly not dangerous for life. The prognosis for recovery is almost always favorable, and in most cases only positional maneuvers are required for the disappearance of all unpleasant symptoms.

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

Clinic of Professor Kinzersky, a cognitive video about benign paroxysmal positional dizziness: