Emory Researchers Report Ways To Diagnose And Treat Patients With Vertigo

Ronald J. Tusa, M.D., Ph.D., professor of Neurology, Emory University School of Medicine, and director of Emory’s Dizziness and Balance Center and Susan J. Herdman, P.T., Ph.D., Emory University School of Medicine, will report at the American Academy of Neurology meeting, in Philadelphia, successful diagnostic procedures and treatment options for BPPV.

BPPV is caused by misplaced calcium carbonate crystals (otoconia) in the semicircular canals (SCC) in the inner ear that have broken free and are found in the fluid of the inner ear. When the head is moved in certain positions, it causes brief periods of vertigo.

"Patients with BPPV usually complain of vertigo in the morning when they get up or turn over in bed," according to Dr. Tusa. "It can also occur when the patient lies down in bed or tilts the head backwards, maybe while taking a shower or sitting in a dentist chair." Patients also complain of poor balance and trouble walking that may last for several hours following an episode of positional vertigo.

BPPV can affect three areas of the SCC, the posterior, the anterior and the horizontal SCCs. The most common is the posterior SCC.

Drs. Tusa and Herdman have studied several ways to diagnose and treat patients with BPPV. "A common test used to confirm the diagnosis of BPPV is the Dix-Hallpike test," says Dr. Herdman. "It involves turning the head to a certain degree while the patient is sitting, then quickly lying the patient back so the head is hanging off the examination table. If the patient has BPPV, the patient should feel a sense of dizziness." Patients can also be tested for BPPV using a sidelying test and a test of balance.

According to Drs. Tusa and Herdman, there are three basic bedside treatments for BPPV, all of which take less than five minutes to administer. They are canalith repositioning treatment (CRT), Liberatory treatment and Brandt-Daroff (BD) treatment.

CRT is used on patients with severe canalithiasis (free-floating otoconia). It is effective in 85-95% of patients with one treatment. Liberatory treatment is effective in dislodging otoconia attached to the cupula (the cover of the semicircular canals). This procedure has a success rate of 53% after one treatment and 76-90% after two treatments. However, this treatment is difficult to perform on elderly patients because of the quickness of the procedure. The BD treatment is a series of repetitive exercises that works by dispersing free-floating otoconia and possibly by dislodging any otoconia attached to the cupula. This is the best treatment for mild canalithiasis, when the patient still has symptoms but no signs of BPPV after a single treatment. BD treatment can also be used in patients with severe BPPV, but it is not the first choice since it causes vertigo and takes up to two weeks for success.

In all of the treatments, patients come to the Dizziness and Balance Center and undergo evaluation, testing and treatment by Drs. Tusa and Herdman. Then, in many cases, the patients learn how to administer the treatment themselves and can perform them at home. There are still more ways to treat other forms of BPPV in the anterior and horizontal SCCs. "Treatment varies according to the SCC involved, whether the otoconia is free-floating or attached to the cupula and the severity of the vertigo," says Dr. Tusa. "We hope our research will be of assistance to a number of people who haven’t been able to find relief from their vertigo elsewhere."

Emory’s Dizziness and Balance Center uses a multidisciplinary approach for diagnosis and treatment. It features physicians and therapists trained in neurology, ophthalmology, otolaryngology, psychiatry and physical therapy. Specialized equipment, including a rotary chair to measure eye movements during head rotation and a dynamic platform posturography to test balance, help provide key information to aid in proper diagnosis.

Dr. Tusa, who holds joint appointments in the Emory Departments of Neurology, Ophthalmology and Otolaryngology, is the founder and former director of the University’s of Miami’s Dizziness and Eye Movement Center. Before that, he spent 13 years at Johns Hopkins University, where he began his research in vision and eye movement. He is the author of two books and numerous chapters and articles for professional journals concerning disorders of the eyes and ears.

Dr. Herdman supervises the Center’s Vestibular Rehabilitation Program, which includes balance and vestibular or inner ear retraining through a series of special exercises. She is the author of the nation’s most utilized textbook on vestibular rehabilitation.