Specialised ENT Services in Gandhinagar & Ahmedabad | Niraaya Hospital

BPPV is the single most common cause of vertigo - responsible for approximately 20% of all dizziness presentations and over 50% of all peripheral vertigo cases. It occurs when otoconia - tiny calcium carbonate microcrystals embedded in a gelatinous membrane on the sensory receptor of the utricle - become dislodged and migrate into one of the three semicircular canals. When the head moves in the plane of the affected canal, the free-floating otoconia deflect the cupula (the mechanosensory receptor at the end of each canal) and generate a false signal of rotation, causing a brief but intensely distressing episode of vertigo.

Classic BPPV presents as sudden, brief (typically less than 1 minute, often 15-30 seconds), intensely spinning vertigo triggered by specific head position changes: rolling over in bed, lying down from sitting, sitting up from lying, looking up to a high shelf, bending forward to pick something up, or extending the neck. Between episodes, the patient may feel mildly unsteady but is generally symptom-free.

Diagnostic tests: The Dix-Hallpike test (for posterior semicircular canal BPPV - the most common) and the Supine Roll test (for lateral semicircular canal BPPV) are performed in the clinic. A characteristic fatigable rotatory nystagmus (involuntary oscillation of the eyes) is observed during the provoking position, confirming the diagnosis.

Treatment: The Epley Canalith Repositioning Manoeuvre is the definitive treatment for posterior canal BPPV. It is a specific sequence of four head and body positions held for 30 seconds each, designed to guide the displaced otoconia out of the semicircular canal and back into the utricle where they can no longer cause symptoms. Performed in the clinic by Dr. Patel, the Epley manoeuvre resolves BPPV completely in approximately 80-90% of patients in a single treatment session. A Semont (liberatory) manoeuvre or the BBQ Roll (360 horizontal rotation manoeuvre) is used for lateral canal BPPV. Home exercises (Brandt-Daroff exercises) are prescribed for maintenance and to reduce recurrence risk.

Meniere's disease (endolymphatic hydrops) is a chronic, fluctuating disorder of the inner ear caused by abnormal accumulation and pressure of endolymph - the fluid filling the membranous labyrinth of the cochlea and vestibular organs. The exact aetiology remains incompletely understood but involves a combination of genetic predisposition, immune mechanisms, viral triggers, and possibly allergy.

The disease produces characteristic, episodic "crises" or "attacks" comprising all four of the following: episodic rotatory vertigo lasting 20 minutes to several hours (rarely more than 12 hours); fluctuating low-frequency sensorineural hearing loss (typically worst during an attack and often partially recovering between attacks in the early stages); tinnitus (usually a low-pitched roaring, humming, or rumbling sound in the affected ear); and aural fullness (a sensation of pressure or blockage in the ear, typically preceding or accompanying an attack). Over time, across multiple attacks over months to years, both the hearing loss and tinnitus become progressive and permanent.

• Dietary modification: Strict low-sodium diet (less than 1500 mg/day) is the single most important lifestyle change - reducing endolymph volume and pressure
• Fluid management: Adequate hydration; avoidance of caffeine and alcohol (both affect inner ear fluid dynamics)
• Diuretics: Acetazolamide or combination diuretics reduce endolymph pressure
• Betahistine: A histamine analogue that increases microcirculation in the inner ear; used as a preventive medication, typically at higher doses (48 mg twice daily)
• Acute attack management: Vestibular suppressants (prochlorperazine, cinnarizine), anti-emetics
• Intratympanic therapy for refractory Meniere's:

- *Intratympanic corticosteroids:* Steroid solution injected through the eardrum into the middle ear, diffusing into the inner ear; effective for vertigo control in many patients while preserving hearing
- *Intratympanic gentamicin:* A targeted, low-dose aminoglycoside antibiotic injected into the middle ear; selectively ablates the vestibular end organ of the affected ear, eliminating vertigo in 70-85% of patients, at the cost of some residual hearing in that ear (used in patients with poor serviceable hearing in the affected ear)

Vestibular neuritis is an acute vestibular syndrome caused by viral or post-viral inflammation of the superior vestibular nerve (the main branch of the vestibular nerve innervating the horizontal and anterior semicircular canals and the utricle). Patients present with sudden, severe, continuous rotatory vertigo - typically lasting days, not seconds or hours - accompanied by intense nausea, vomiting, and marked unsteadiness, but crucially without hearing loss.

Labyrinthitis is similar but additionally involves the cochlea - the labyrinthitis patient therefore also has hearing loss in the affected ear alongside the vertigo episode.

Both conditions are thought to be caused by reactivation of latent herpes simplex or varicella-zoster virus in the vestibular ganglion, analogous to Bell's palsy for the facial nerve.

Management: High-dose oral corticosteroids (prednisolone) begun within the first 72 hours may improve final vestibular nerve function recovery. Short-term vestibular suppressants reduce acute nausea. Critically - early vestibular rehabilitation therapy (VRT) is the most important intervention for accelerating central compensation and restoring balance - the brain must be challenged, not sedated, to adapt to the vestibular asymmetry.

• Dix-Hallpike and Supine Roll tests for BPPV diagnosis
• Video Head Impulse Test (vHIT) - assesses vestibulo-ocular reflex gain in all six semicircular canals
• Pure-tone audiometry and tympanometry - cochlear function assessment
• Caloric testing - assesses each labyrinth independently by irrigating warm and cool water alternately
• Vestibular Evoked Myogenic Potentials (VEMP) - saccular and utricular function testing
• MRI Internal Auditory Meatus - rules out vestibular schwannoma and central causes

• Epley, Semont, and BBQ Roll manoeuvres for BPPV
• Structured Vestibular Rehabilitation Therapy (Cawthorne-Cooksey exercises, gaze stabilisation, balance retraining, habituation exercises)
• Betahistine and pharmacological management
• Dietary and lifestyle counselling for Meniere's disease
• Intratympanic steroid injections (in-clinic procedure)
• Referral for intratympanic gentamicin or surgical management in refractory Meniere's