Otolithiasis, also known as benign paroxysmal positional vertigo (BPPV), is the most common peripheral vestibular disorder. It presents with transient vertigo and characteristic nystagmus when the head moves to a specific position. It is often self-limited and prone to recurrence. Its etiology is complex, with some patients remaining unexplained and others experiencing secondary medical conditions.
Clinical classification
1. Classification by cause
(1) Idiopathic otolithiasis: The cause is unknown, accounting for about 50% to 97%.
(2) Secondary otolithiasis: secondary to other otological or systemic diseases.
2. Classification by affected semicircular canals
(1) Posterior semicircular canal otolithiasis: the most common, accounting for about 70% to 90%.
(2) Lateral semicircular canal otolithiasis (horizontal semicircular canal otolithiasis): accounts for about 10%~30%.
(3) Anterior semicircular canal otolithiasis: a rare type, accounting for about 1% to 2%.
(4) Multiple semicircular canal otolithiasis: The ipsilateral semicircular canal or bilateral semicircular canals are affected simultaneously, accounting for about 9.3% to 12%.
Epidemiology
Contagious
Not contagious.
Incidence
The annual incidence of otolithiasis reported so far is (10.7~600)/100,000, the annual prevalence is about 1.6%, and the lifetime prevalence is about 2.4%.
Incidence trend
The incidence of otolithiasis increases gradually with age.
High-risk population
The male-to-female ratio is 1:1.5~1:2.0, and the incidence is usually higher after the age of 40.
Causes
Overview
About half of patients have an unknown cause, which is idiopathic otolithiasis. Secondary otolithiasis is secondary to other diseases, the most common causes being head trauma and vestibular neuritis.
Basic cause
1. Idiopathic otolithiasis
The cause is unknown. It may be related to accelerated otolith degeneration, decreased absorption capacity, and reduced stability of the otoliths due to aging. Hormone changes, calcium metabolism disorders, and osteoporosis may also be predisposing factors.
2. Secondary otolithiasis
(1) Secondary to head trauma, especially a few days or weeks after a mild head trauma, or sudden acceleration or deceleration while riding in a vehicle causing “whiplash” to the neck.
(2) Other ear diseases, such as otitis media and mastoiditis, post-ear surgery, drug-induced ototoxicity, etc.; or other inner ear diseases, such as Meniere’s disease, idiopathic sudden deafness, etc.
(3) Viral neuritis.
(4) Transient ischemic vertigo of the vertebral basilar artery and inner ear blood circulation disorder.
(5) Abnormal systemic calcium ion metabolism may be related to the occurrence of this disease.
Predisposing factors
1. The direction of gravity changes the head position, such as leaning the head forward, tilting the head back, turning over in bed, turning the head quickly, etc.
2. Excessive fatigue, mental stimulation, and psychological stress may also induce otolithiasis.
symptom
Overview
The main symptoms of otolithiasis are transient vertigo after changing head position, accompanied by nystagmus, nausea, and vomiting. The dizziness may be followed by a feeling of lightheadedness, floating, and instability.
Typical symptoms
The primary manifestation is sudden onset of intense rotational vertigo accompanied by nystagmus. Symptoms often occur when changing from a sitting position to a lying position, from a lying position to a sitting position, or when turning over in bed. Vertigo attacks often awaken the patient during sleep. The vertigo and nystagmus quickly disappear after maintaining the same head position. A single episode typically lasts from a few seconds to tens of seconds, rarely exceeding a minute, and symptoms recur with the next change of head position.
2. The degree of vertigo varies greatly. In severe cases, it occurs with the slightest movement of the head. After the vertigo attack, there may be a long period of feeling of heaviness, floating and instability.
Associated symptoms
May be accompanied by autonomic nervous system symptoms such as nausea and vomiting.
complication
This disease generally has no obvious complications.
examine
Scheduled inspection
If you experience dizziness after changing your head position, accompanied by symptoms such as nystagmus, nausea, and vomiting, you should seek medical attention immediately. Your doctor will first perform a physical examination to determine the underlying condition. They will then conduct audiological and balance tests to determine if there are any abnormalities in your hearing and balance. CT or magnetic resonance imaging (MRI) may be necessary.
Physical examination
1. Dix-Hallpike test
This is an important routine examination method for posterior and anterior semicircular canal otolithiasis. During the examination, the patient sits on the examination couch with their head turned 45° to one side. The physician, standing to the patient’s side, holds the patient’s head with both hands, maintaining the 45° angle. The patient then quickly lies down, with their head suspended 20° above the horizontal plane over the edge of the bed. The patient is observed for 30 seconds or until the nystagmus subsides, after which the head and upper body return to an upright sitting position. Next, the examination is performed with the head suspended to the opposite side.
2. Roll test
This is a routine examination method for lateral semicircular canal otolithiasis. During the examination, the patient lies flat on the examination table with their head elevated 30 degrees. The physician holds the patient’s head with both hands and quickly turns the head 45 degrees to the left or right. The physician observes the patient for one minute or until the nystagmus stops. The contralateral nystagmus is also observed.
Imaging examinations
Temporal bone CT and high-resolution magnetic resonance imaging (MRI) of the inner ear and pons and cerebellum are not routine examinations, but can provide diagnostic clues for some atypical or refractory otolithiasis.
Other tests
1. Audiological examination
Generally, there are no abnormal audiological changes, but if semicircular canal stones are secondary to certain ear diseases, hearing abnormalities may occur in the affected ear.
2. Vestibular function test
It includes tests such as caloric test, rotation test, head impulse test and vestibular muscle evoked potential, which are mainly used to determine the location, nature, degree and central compensation of vestibular dysfunction.
3. Balance function check
Static or dynamic posturography, balance sensory integration ability test and gait evaluation, etc.
diagnosis
Diagnostic principles
Doctors usually carefully inquire about the patient’s medical history, such as history of head trauma, ear disease, etc., to understand the characteristics, severity and accompanying symptoms of the symptoms, and can usually make a diagnosis in combination with relevant auxiliary examinations.
Diagnostic basis
1. Symptom characteristics
Recurrent, brief episodes of vertigo or dizziness (usually lasting less than 1 minute) that occur after a change in head position relative to gravity.
2. Position test
Vertigo and characteristic positional nystagmus occur during positional testing, and the nystagmus features are consistent with the excitation or inhibition of the corresponding semicircular canal:
(1) Posterior semicircular canal otolithiasis: When the affected ear is turned toward the ground, a vertical upward nystagmus with a torsional component occurs (the vertical component is upward, and the torsional component is downward). The direction of the nystagmus is reversed when the patient returns to a sitting position.
(2) External hemicanalicular otolithiasis: Bilateral position tests can induce horizontal geotropic or horizontal alotropic nystagmus.
(3) Anterior semicircular canal otolithiasis: When the affected ear is facing the ground, vertical torsional nystagmus occurs with the upper pole of the eyeball as the mark (the vertical component is toward the lower pole of the eyeball, and the torsional component is toward the ground, but the torsional component of the nystagmus may not be obvious in some patients); the direction of the nystagmus reverses when the patient returns to a sitting position.
3. Rule out other diseases
Such as central positional vertigo, Meniere’s disease, vestibular neuritis, superior semicircular canal dehiscence syndrome, etc.
Differential diagnosis
1. Central vertigo
It is vertigo caused by brain diseases, the most common of which is “vertebral basilar insufficiency”, which is mostly gradual and continuous, and the attack time can sometimes last for several months.
2. Meniere’s disease
The characteristic manifestations of Meniere’s disease are recurrent attacks of rotational vertigo and fluctuating sensorineural hearing loss, often accompanied by tinnitus and/or a feeling of fullness in the ears.
3. Vestibular neuritis
Vestibular neuritis may be caused by a viral infection. Clinically, it is characterized by sudden onset of vertigo, spontaneous nystagmus directed to the unaffected side, nausea, and vomiting. Vestibular function is weakened, but tinnitus and deafness are absent. Symptoms gradually subside after a few days, but can develop into positional vertigo that persists for several months. Relapse is rare after recovery.
4. Superior semicircular canal dehiscence syndrome
The clinical manifestations are vertigo, vibration sensation in the ear and balance disorders induced by strong sound stimulation, changes in middle ear pressure or intracranial pressure.
treat
Treatment principles
While otolithiasis is somewhat self-limiting, it can recur and, in severe cases, lead to loss of ability to function or work. To alleviate symptoms as quickly as possible, treatment should be sought, with otolith repositioning being the most effective. Doctors may also prescribe medications and, if necessary, surgery, depending on the patient’s specific condition.
Drug treatment
In principle, medication cannot reposition otoliths. However, drug-assisted treatment may be considered in the following situations:
1. When combined with other diseases, drugs should be given to treat such diseases at the same time.
2. If symptoms such as dizziness and balance disorders occur after reduction, the doctor may give drugs to improve the inner ear microcirculation, such as promethazine, betahistine, ginkgo leaf extract, etc.
Related drugs
Promethazine, Betahistine
Surgical treatment
For a very small number of patients with otolithiasis who still have persistent disease after manual reduction and have a great impact on their daily work and life, semicircular canal occlusion and posterior ampullary nerve transection can be considered, but the latter has been used less and less in recent years.
Other treatments
1. Otolith repositioning
(1) Epley method: This is the most commonly used technique for treating posterior semicircular canal otolithiasis. This method changes the patient’s head position in sequence, allowing the otoliths to move under the action of gravity and be discharged from the posterior semicircular canal. During repositioning, the patient needs to sit on the treatment bed with the head turned 45° to the affected side; with the help of the doctor, quickly take a supine position with the head hanging on the edge of the bed; turn the head 90° to the healthy side; the doctor will turn the patient’s head and body 90° to the healthy side, so that the patient lies on the treatment bed. At this time, the head deviates from the supine position by 135°; return to a sitting position, completing a treatment cycle. Each of the above positions should be maintained for at least 30 to 60 seconds or until the nystagmus disappears. The entire treatment process needs to be repeated until there is no dizziness or nystagmus in any position, and then repeat 2 to 3 cycles.
(2) Lempert method: also known as Barbecue rolling method, used to treat horizontal semicircular canal otolithiasis.
2. Otolith repositioning instrument assists repositioning
It can be used as a reduction treatment option and is suitable for patients who have difficulty with manual reduction.
3. Vestibular rehabilitation training
Vestibular rehabilitation is a physical training method that improves vestibular function through central adaptation and compensatory mechanisms, mitigating the sequelae of vestibular injury. Vestibular rehabilitation can be used as an adjunct to otolith repositioning for patients who experience dizziness or balance impairment after repositioning or who experience ineffective repositioning. It can also be used before repositioning to increase tolerance. If a patient refuses or cannot tolerate repositioning, vestibular rehabilitation can serve as an alternative.
Treatment cycle
The treatment cycle of otolithiasis may vary from person to person due to factors such as the severity of the disease, treatment plan, timing of treatment, age and physical condition.
Treatment costs
The treatment costs of otolithiasis may vary significantly among individuals, and the specific costs are related to the selected hospital, individual treatment plan, medical insurance policy, etc.
Prognosis
General prognosis
The disease is self-limiting to a certain extent, and some patients can recover on their own without treatment, but its course is uncertain and sometimes can last for months or even years. Severe cases can lead to loss of work and life ability.
Hazards
1. Patients with otolithiasis may experience dizziness during the onset of the disease, which may lead to falls due to loss of balance.
2. If the disease lasts for a long time and recovery is not good for a long time, it may lead to loss of ability to live and work.
Self-healing
Otolithiasis is self-limiting to a certain extent, with a natural course of several days to several months. About 50% of patients recover within a month, and sometimes it may take several months or even years.
Curative
Symptoms can be relieved through active treatment.
Cure rate
Symptoms of most patients can be relieved after otolith repositioning.
Recurrent
This disease can recur.
daily
Overview
Reasonable nursing measures can help improve treatment outcomes and promote recovery. Patients should maintain a cheerful mood in their daily lives, pay attention to their own safety, and try to avoid falls.
Psychological care
1. Psychological characteristics
(1) Otolithiasis may recur, and patients may lose confidence in treatment.
(2) During an attack, the patient will experience severe rotational vertigo, which may cause panic and anxiety.
2. Nursing measures
(1) Family members should pay more attention to the patient’s emotional changes, give the patient full respect, understanding and care, and help the patient build confidence in overcoming the disease.
(2) Patients should maintain a good attitude and relieve negative emotions by listening to soothing music, playing chess, etc.
Medication care
Those taking medication should strictly follow their doctor’s instructions and avoid increasing the dosage on their own to avoid adverse consequences. During medication use, pay attention to monitor yourself for any other discomfort. If you experience any discomfort, you should report it to your doctor immediately and a professional physician will make the appropriate assessment.
Life Management
1. Patients with otolithiasis may experience recurrent vertigo and should focus on avoiding factors that cause vertigo, such as turning the head quickly, bending over, and turning the body.
2. Patients can carry a cane when going out, which can help support the body and prevent falls during vertigo attacks.
3. Set up night lighting facilities at home to ensure good lighting when getting up at night.
4. Patients may experience dizziness when turning over, so guardrails should be installed on the bed to prevent them from falling out of bed.
Special care
1. After reduction, you need to adopt a compulsory body position, take a semi-recumbent position, raise the head of the bed 45 degrees, and raise your head to an upright position for 48 hours. During this period, avoid lying on your side, lowering your head, bending over, etc. You can use a neck brace for fixation. You can sit up when washing or eating, with your head slightly tilted forward. Be careful to avoid the head tilting back or forward too much.
2. Because the forced position will affect the patient’s normal life and affect their ability to take care of themselves, family members should actively provide assistance to the patient during eating, drinking, brushing teeth, washing face, etc. If necessary, they can assist the patient to urinate and defecate in bed.
3. After 48 hours of reduction, the patient can slowly resume normal activities, but cannot lie on the affected side within 7 days. The patient should try to adopt a semi-recumbent position on the healthy side to prevent the otoliths from returning to the semicircular canals.
diet
Dietary adjustment
This disease usually does not have special dietary requirements, but a reasonable daily diet and developing good eating habits can play a certain positive role in the body’s recovery.
Dietary recommendations
1. Combine meat and vegetables to ensure balanced nutrition.
2. Eat more high-protein and high-vitamin foods in daily life.
3. Patients may experience loss of appetite due to discomfort symptoms such as dizziness. Family members can change the cooking method and make some sweet and sour foods to promote the patient’s appetite.
Dietary taboos
1. Eat less fried, grilled, and greasy foods, such as fried chicken chops, grilled lamb chops, etc.
2. Eat less or no pickled foods, such as salted duck eggs, pickles, etc.
3. Do not eat spicy and irritating foods, such as onions, garlic, peppers, etc.
4. Avoid smoking and drinking.
prevention
Preventive measures
The cause of idiopathic otolithiasis is unknown, and there are currently no effective preventive measures; secondary otolithiasis can be reduced to a certain extent by actively treating ear diseases (such as otitis media, Meniere’s disease, etc.), protecting the head, and avoiding head trauma as much as possible.
Medical Guide
Home treatment
When vertigo strikes, you should pay attention to:
1. The patient himself
Rest on the spot or find something to lean on nearby to avoid falling and getting injured.
2. People around you
(1) Monitor their vital signs and consciousness;
(2) Clear obstacles in the surrounding environment and pay attention to the anti-slip ground;
(3) Adjust the patient’s position to prevent falls and injuries. If the patient is in bed, raise the bedside guardrail. If the patient is standing, help the patient to a chair.
(4) If symptoms continue to worsen, seek medical attention immediately.
Outpatient indications
1. Recurrent dizziness;
2. Accompanied by autonomic nervous system symptoms such as nausea and vomiting;
3. Accompanied by a feeling of lightheadedness, floating, and instability;
4. Other severe, persistent or progressive symptoms and signs occur.
All of the above require prompt medical consultation.
Treatment department
If you suddenly experience dizziness after changing your head position, you should be alert to the possibility of otolithiasis and see an ENT department doctor promptly.
Medical preparation
1. Make an appointment in advance and bring your ID card, medical insurance card, medical card, etc.
2. If you have had medical treatment recently, please bring relevant medical records, examination reports, laboratory test results, etc.
3. If you have taken some medicine to relieve symptoms recently, you can bring the medicine box with you.
4. Arrange for family members to accompany the patient to seek medical treatment.
5. Patients can prepare a list of questions they want to ask in advance.
Questions your doctor may ask
1. How long have you been experiencing vertigo? Is this the first time?
2. Are there any triggering factors before the onset of vertigo?
3. When do your vertigo symptoms get worse? When do they get better?
4. In addition to vertigo, do you have any other symptoms, such as nausea, vomiting, deafness, or tinnitus?
5. Have you ever had cardiovascular diseases such as hypertension?
6. Do you have a history of Meniere’s disease, vestibular neuritis, etc.?
7. Have you ever had middle ear, maxillofacial, or orthopedic surgery before?
8. Have you ever taken any special medications?
What questions can patients ask?
1. What is my illness? What is the cause?
2. Is my condition serious? What tests do I need?
3. What treatment methods do I need now? Is it curable?
4. I have other diseases. Will this affect my treatment?
5. What should I pay attention to after returning home?
6. If medication is required, what are the usage, dosage, and precautions?
7. Do I need follow-up examinations? How often?