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Dr. Hernan Goldsztein is now a full partner with Pacific ENT Medical Group, Inc.

Dr. Hernan Goldsztein was selected as a Top Doctor in Otolaryngology by his peers in 2017 and 2018 as featured in San Diego Magazine.

Dr. Moses Salgado and Dr. Hernan Goldsztein were featured as “Champions for Health” in San Diego Physician Magazine because of their volunteer work with patients in Project Access San Diego

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Benign Paroxysmal Positional Vertigo

“Loose crystals in the inner ear”

Benign paroxysmal positional vertigo (BPPV) is a very common cause for vertigo. Vertigo is the feeling that you or the world around you is spinning. Paroxysmal means that the vertigo comes in short, sudden spells. Positional means that the vertigo is triggered with a change in head position or with head movement.

The inner ear has 2 main functions hearing and balance. The anterior half is responsible for hearing while the posterior half is responsible for balance. The posterior half of the inner ear houses the vestibular organ, which includes 3 sets of fluid-filled channels (semicircular canals) on each side of the skull. These 3 channels are distributed in the X, Y and Z-axis and contain sensors to detect movement in any direction.

Vestibular System

Within the vestibular organ there are tiny crystals of calcium carbonate. Movement of the head causes movement of the fluid and also crystals that in turn activate sensors signaling to the brain that the head position has changed. If the crystals become dislodged they can erroneously activate these same sensors. This mixed information disorients the brain causing the subjective feeling of rotation.

We rarely identify the cause of these crystals breaking loose but usual triggers include head trauma, colds, migraine, prolonged periods of lying in bed (illness, surgical procedures), diabetes or osteoporosis. Occasionally we will see it after a dental appointment when power instruments have been used and vibrations were transmitted to the ear.

Symptoms of BPPV include vertigo with head movement that lasts seconds to minutes. Some individuals experience nausea and occasionally, vomiting. The first episode is often the most severe and subsequent episodes less intense. A sense of imbalance may persist after the vertigo occurs and this can actually last for several weeks. Loss of hearing, vision changes and fainting are not associated with BPPV and should point to another diagnosis. If you are having intense symptoms try opening your eyes and focusing on an object as opposed to closing them. This allows you to suppress the spinning sensation by a mechanism called “visual fixation”.

Diagnosis of BPPV is made by examination in the office by the Dix-Hallpike or supine roll over test. Bedside examination involves lying down with the head rotated to the right and then the left side. A “positive” test is one in which the individual experiences vertigo and movement of the eyes called “nystagmus”.

Treatment involves performing an Epley or “repositioning” maneuvers which relocates the crystals into their original location within the inner ear. It involves a series of head movement which can be performed in the office as part of initial examination. There is a high rate of success, about 80%, after 1-3 treatments. The spinning sensation should be significantly diminished after the “repositioning” maneuver, however many individuals may experience some mild instability, or sensation of motion sickness, for a few hours or days following the procedure.
The procedure may be repeated if necessary. There are also self-repositioning techniques to do at home.

Without treatment, BPPV will generally go away with time but may take 1-2 weeks to resolve, followed by several weeks of a sensation of imbalance. If symptoms don’t resolve in this time other diagnosis should be considered.

Exercises may be recommended to help speed recovery from residual unsteadiness. Occasionally, balance therapy is prescribed. Very rarely the condition can become chronic and even less commonly surgery is recommended.

Return to normal activities is encouraged following repositioning maneuvers, however precautions against falling should be observed, especially in older individuals or those with residual unsteadiness.

BPPV may come back, unfortunately nobody can predict when or if it will ever recur. Regardless each episode is treated in the same way as the initial occurrence.

Medications are generally not indicated for BPPV except to temporarily treat immediate symptoms, such as nausea. Audiograms X-rays, scans and laboratory testing are not needed to confirm the diagnosis of BPPV but may be indicated for other causes of vertigo or if there are other associated symptoms.

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