http://neurosurgery.ucsd.edu/vertigo-and-dizziness/ (BPPV)

Warning! This message includes masses & masses of new & confusing words (see bottom).

I woke up on Thursday (10 Dec) morning, turned over onto my left side, and immediately got so dizzy with vertigo that I thought that I might throw up. It took me a long time to get to the toilet, as I had to keep closing my eyes to try to regain balance. I also largely got there by feeling my way via the walls.

The whole thing reminded me of watching the old folks at my father’s nursing home repetitively walking the corridors with their hands on a rail conveniently provided for that purpose. With hindsight, I realise that it also probably killed my dad, since the nurse reported that he “turned suddenly and fell to the floor; he looked up at me and said ‘that was foolish’”. The fall broke his hip, the subsequent hospital stay caused clots & his abrupt return to the nursing home caused a heart attack that killed him. The surgeon responsible avoided all blame by not turning up to the Inquest.

The most likely reason for these symptoms is that--like lots of old folks--that I’ve got Benign paroxysmal positional vertigo (BPPV).

BPPV:

(The Dizzy patient p3): characterized by vertigo and nystagmus ... associated with changes in head position. BPPV can occur after head trauma or prolonged periods of bed rest, or it can be precipitated by assuming unusual positions such as head extension in a dentist’s or hairdresser’s chair. Frequently, BPPV is idiopathic, especially in the elderly.

The same thing also happened on Friday & Saturday morning but, of course, our well-paid GPs are far too posh to work on Saturdays, so I now have to wait until Monday to get this confirmed. I’m fairly sure (after masses & masses of dedication to Google) that it is BPPV:

• sudden in onset
• usually first noticed in bed, when waking from sleep
• triggered by turning the head
• symptoms are violent, but brief (~30 secs)
• symptoms include room-spinning vertigo
• zero hearing loss
• zero ringing in the ears
• subsequent feeling of queasiness (~hours)
• subsequent anxiety (of repeat episodes)

Cause:

In a nutshell: ‘displacement of ear-rocks’. That is going to require a little explanation...

The inner organ that allows us to hear (the cochlea - see illustration at top) is closely associated with the organ that allows us to be able to balance & stand upright (the semi-circular canals) (SCC) (both of them minor miracles of nature). Whilst what we think of as ‘the ear’ is positioned outside our head (the “outer ear”), and the bit that gives us grief by itching is the ear canal (the “middle ear”), the cochlea + SCC are positioned beyond the ear-drum, within the bone behind the mastoid process of the head (the “inner ear”).

The 3 SCC are each at right-angles to each other, which gives the possibility of detecting motion change through all 3D-planes. You may then not be surprised to learn that SCC exist not just in all mammals but also with fish both modern & ancient. Indeed, ear-rocks have been found in very ancient fossils & used to detect the makeup of the ancient seas in which they swum.

The SCC are filled with endolymph (a liquid uniquely characterised by having potassium rather than sodium as it’s main salt constituent) and it is the angular rotation of this fluid that interacts with hair cells within the otolithic organs (utricle and saccule) which lie within the vestibule of the SCC. In humans the utricle macula is horizontal & heart-shaped, while the saccule macula is vertical & hook-shaped:

Those macula begin as hair cells embedded within the underlying epithelium; nerves attached to those cells join the vestibular nerve as a bundle and end within the brainstem. That neural output serves as an input signal to oculomotor reflexes, postural mechanisms and perceptual systems. Therefore, the SCC + macula play a role in generating compensatory eye movements in responses to linear acceleration of the head, and in changes in orientation and static postural functions with respect to gravity. To state it in a nutshell:- without the 2 sets of SCC + macula, we could not even stand up, let alone walk or run.

A gelatinous layer encloses the hair cilia, whilst the surface of this layer is covered with otoconia (the latter can be clearly seen in the photomicrographs above). These otoconia are calcite crystals (‘ear rocks’) ranging in size from 3 to 30 µm (1µm=0.001mm).

Here is a diagram of a cross-section of the whole thing, from top to bottom:

With mention of the otoconia, we have finally reached the villains of this piece. They seem to be established during the embryonic phase (only evidence from studies of rats is quoted in the Dutch journal). A nucleus is established very early in the embryo, which then grows layer-upon-layer of calcium until a critical calcium concentration in the endolymph is achieved.

The basic function of the otoliths is that they have a greater momentum than the hair cilia (due to their size & weight) and therefore amplify external movements of the head more effectively than could the cilia alone. That is great when young. Unfortunately for the old, some tend to break free & then migrate from the macula into one or more of the SCC. In that position they impede free movement of the endolymph, which in turn leads to the extraordinary symptoms that I first experienced that Thursday morning.

Treatment:

Naturally, doctors & surgeons have resorted in the past to terrifying surgical treatments, including sectioning (cutting through) the Vestibular nerve (danger of collateral damage to the auditory + facial nerves, which intermix at this location). Another surgical procedure involves exposing the SCC & packing with tissue to prevent any internal movement. And so it goes on - all crazy in my view.

There is zero point in medications, as they will not fix the basic cause. The modern treatment is to:-

• First, Dix-Hallpike manœuver: initiates Nystagmus, which is proof positive of BPCC. Then,

1. Do nothing
   The patient learns not to turn upon the bad ear, which would initiate BPPC; eventually the symptoms subside.
   
   or,
   
   
2. Otolith Repositioning procedure
   Using the Epley manœuver, or a modified Epley manœuver, or a Semont liberatory manœuver. These can be augmented by applying a vibrator (stop giggling at the back, you boys) to the mastoid bone during the procedure, as to help dislodge the otoconia.
   
   The purpose of all these procedures is to move the otoconia from a SCC (where it is causing BPPV) to the Vestibule (where it will not).

Later addition:
My GP has a 3-second window in the morning and afternoon during which you are allowed to make an appointment (the actual window is larger than that, but does not seem like it). I missed that window.

I used my research into Otolith Re-positioning to do a little myself (it did help). The Nystagmus also naturally subsided. Thank god.

---------
Alex Kemp