Eur Arch Otorhinolaryngol (2009) 266:1831–1835 DOI 10.1007/s00405-009-0938-3
C A S E RE P O RT
Benign paroxysmal positional vertigo after intense physical activity: a report of nine cases Pier Giorgio Giacomini · Simona Ferraro · Stefano Di Girolamo · Irene Villanova · Fabrizio Ottaviani
Received: 3 June 2008 / Accepted: 19 February 2009 / Published online: 14 March 2009 © Springer-Verlag 2009
Abstract The aim of this study was to report some clinical cases suggesting a possible correlation between benign paroxysmal positional vertigo (BPPV) and intense physical activity. Out of 430 BPPV cases referred to our out-patients clinic, 9 patients, showing symptoms of BPPV arising after an intense period of physical activity, were selected for this study. The posterior semicircular canal was aVected in all the nine patients. The canalith repositioning procedure was successful and eliminated vertigo and nystagmus in all patients. During the follow-up period (12 months) all patients continued with the usual physical activity; four of the nine patients showed a recurrence of the BPPV symptoms after a new intense period of exercises: all were successfully treated by a new single Epley repositioning procedure. BPPV due to intense physical activity is a rare condition (9/430) and it may be caused by repeated vibratory vertical accelerations of a minor degree associated with metabolic variations during strenuous exercise.
P. G. Giacomini · S. Ferraro · S. Di Girolamo · F. Ottaviani Otolaryngology Division, University of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy P. G. Giacomini e-mail:
[email protected] S. Ferraro e-mail:
[email protected] S. Di Girolamo e-mail:
[email protected] F. Ottaviani e-mail:
[email protected] I. Villanova (&) ENT Division, PTV, Viale Oxford 81, 00133 Rome, Italy e-mail:
[email protected]
Keywords Benign paroxysmal positional vertigo · Physical activity · Labyrinth lithiasis · Otoconia
Introduction Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo. It is characterized by episodes of dizziness and nystagmus, lasting a few seconds, caused by sudden head movements, often when the patient is turning in bed, standing up from the bed or lying down from an upright position. The 1 year incidence of the disease is reported to be 0.6% [1]. The average age of onset is 50–60 years, with the incidence increasing with age [2], women are more aVected than men, with a 2:1 ratio [3]. The most accepted pathophysiology is the detachment of the otoliths from the macula utriculi and their dislocation into semicircular canals. Although most of the cases are idiopathic, BPPV can be a complication of several diVerent conditions. Head trauma, viral infection, ischemic accidents, hydrops and ear surgery are usual associated conditions [4]. SpeciWcally head trauma, tooth implantations and ear surgery have been advocated [5–7]. Head trauma could throw otoconial debris into diVerent canals of each labyrinth and be responsible for combined horizontal and posterior forms of BPPV [5]. A forced head positioning lying on the back during dental implant surgery and inner ear trauma induced by dental turbine noise working in the maxillary bone [8] as well as the blunt head trauma caused by osteotomy can induce loosening of otoconia from the utricle [9]. A vibratory trauma caused by drilling the cochlea during cochleostomy would be also suYcient to dislodge otoconia into the labyrinth [10].
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1832 Table 1 Population proWle
CSP Posterior semicircular canal, CRP canalith repositioning procedure, tr treadmill
Eur Arch Otorhinolaryngol (2009) 266:1831–1835
Sex
Age
Sport
Canal
Side
No. CRP
Maneuver
Recurrence
Women
16
Swimming
CSP
Left
1
Epley
0
Women
27
Aerobics
CSP
Right
1
Epley
0
Women
30
Aerobics
CSP
Left
1
Epley
1
Women
55
Acquarobics
CSP
Left
2
Epley
1
Men
47
Marathon
CSP
Right
1
Epley
1
Women
25
Jogging
CSP
Left
1
Epley
0
Men
35
Jogging tr
CSP
Left
1
Epley
0
Men
31
Swimming
CSP
Right
1
Epley
1
Women
36
Aerobics
CSP
Left
1
Epley
0
Fig. 1 Epley repositioning maneuver (right posterior semicircular canal BPPV)
It appears that posttraumatic BPPV is more diYcult to treat than idiopathic BPPV, and also has a greater tendency to recur [11]. To date, to our knowledge speciWc links between BPPV and sport activity have been reported only in extreme mountain biking [12] and swimming [13]. The aim of this study was to report some clinical cases suggesting a possible correlation between BPPV and intense physical activity of diVerent kinds which are not previously described.
Case reports Out of 430 cases of BPPV (307 women, 123 men, mean age 57.3 years: range 15–83 years) examined for BPPV between January 2006 and January 2008 in the out-patient clinic of the Department of Otolaryngology, University of Rome “Tor Vergata”, 9 (2.1%) patients (6 women and 3 men, mean age 33.4 years: range 16–55 years) showing symptoms of BPPV after a physical sport activity otherwise healthy were selected for this study. BPPV followed an intense period of aerobics (3 patients), dolphin stroke-style swimming (2 patients), jogging (1 patient), jogging on a treadmill (1 patient.), aquarobics (1 patient), marathon running (1 patient) (Table 1). In all patients history, physical and otoneurological examinations were performed including: audiological test, evaluation of spontaneous nystagmus and positional nystagmus, evoked nystagmus by Dix–Hallpike and McClure maneuver using infrared electronystagmoscopic observation, electronystagmography (ENG).
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The audiological test consisted of pure tone and impedance audiometry. The assessment of evoked nystagmus consisted of eliciting nystagmus by head positioning, such as the Dix–Hallpike maneuver [14] for diagnosis of canalithiasis of the posterior semicircular canal (PSC) and McClure–Pagnini maneuver [15] for diagnosis of canalithiasis of the lateral semicircular canal (LSC). The Dix–Hallpike and McClure– Pagnini maneuvers were carried out according to literature [14, 15]. Electronystagmography was employed for evaluation of saccades and smooth pursuit eye movements (Racia, Bordeaux, France) asking the patient to pursue a light spot quickly moving on a horizontal bar in front of them [16]. All the patients were submitted to posterior semicircular canalith repositioning procedure according to Epley (Fig. 1). All of the patients were re-evaluated clinically 1 week after the canalith repositioning procedure, repeating the diagnostic tests, and monthly by phone interview for 8– 12 months. Repeated physical examinations and clinical diagnostic tests were carried out in case of relapsing BPPV. Ethical considerations Written informed consent to participate in the case report was obtained from all nine patients. Case 1 A 16-year-old white female in good physical shape was attending swimming activity three times per week. After an
Eur Arch Otorhinolaryngol (2009) 266:1831–1835
intense dolphin stroke-style swimming activity the patient complained of vertigo and nausea lasting 1–2 min. Symptoms persisted next day related to head movements. Left PSC BPPV was diagnosed and the patient underwent Epley’s maneuver. The symptoms and nystagmus disappeared after the Wrst session. There was no recurrence during the 12 months follow-up.
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rotatory vertigo after a particularly intense marathon running activity. Right PSC BPPV was diagnosed, Epley’s maneuver was done and symptoms and nystagmus disappeared after the Wrst session. After 4 months he showed a recurrence of a right PSC BPPV during a new intensive marathon running activity and he was successfully treated again by a single Epley’s reposition procedure. No further relapses were observed.
Case 2 Case 6 A 27-year-old white female was attending aerobics activity two to three times per week. She complained of intense positional rotatory vertigo after a particularly intense aerobics exercise involving a lot of jumping with vertical accelerations that might dislodge otoliths from the utricular macula. Right PSC BPPV was diagnosed and Epley’s maneuver was done. On a check-up visit after 1 week she felt better and nystagmus disappeared. No recurrence was reported. Case 3 A 30-year-old white female experienced vertigo and vomiting started since 24 h after intense aerobics activity. The Dix–Hallpike maneuver showed a left PSC BPPV. Epley’s procedure was performed once and nystagmus disappeared. During the follow-up period she showed a recurrence of left PSC BPPV after a repeated intense aerobics activity. She was successfully treated again by a single Epley’s reposition procedure. No further recurrence was seen. Case 4 A 55-year-old white female was regularly attending aquarobics activity two times per week. During an intense series of aquarobic exercise consisting of numerous jumps she complained of acute rotatory vertigo with symptoms and paroxysmal positional nystagmus typical for canalithiasis of the left PSC. Epley’s maneuver was done. The patient was re-evaluated after 1 week: she felt better but nystagmus persisted during diagnostic test. Therefore, she was successfully submitted to a second Epley’s maneuver. During the follow-up period she pursued the habitual sport and after 6 months she showed a recurrence of left PSC BPPV during a new intensive aquarobics activity. The patient was successfully treated again by a single Epley’s reposition procedure. No further recurrence was seen. Case 5 A 47-year-old white male in good physical shape was attending jogging three times per week and marathon running once a month. He complained of intense positional
A 25-year-old white female attending a jogging activity twice a week complained of vertigo started after an intense jogging activity. Dix–Hallpike maneuver showed a left PSC BPPV. Epley’s reposition procedure was performed and nystagmus disappeared after one session. During the follow-up period no recurrence was reported. Case 7 A 35-year-old white male attended jogging on a treadmill three times per week. During an intense series of jogging on the treadmill he felt sick and complained of acute rotatory vertigo with symptoms and paroxysmal positional nystagmus typical for canalithiasis of the left PSC was observed. Epley’s maneuver was done and symptoms and nystagmus disappeared after the Wrst session. No recurrence was reported. Case 8 A 31-year-old white male regularly attended a swimming activity twice a week. After an intense dolphin stroke-style swimming activity the patient complained of vertigo and nausea lasting a few minutes. Right PSC BPPV was diagnosed and Epley’s maneuver was done. On a check-up visit 1 week later he felt better and nystagmus disappeared after the Wrst session. After 8 months he showed a recurrence of a right PSC BPPV during an intensive swimming activity and he was successfully treated again by a single Epley’s reposition procedure. No recurrences were reported. Case 9 A 25-year-old white female was attending aerobics activity two to three times per week. During an intense series of aerobic exercise she felt sick and had to interrupt the aerobic lesson because of the acute rotatory vertigo. Dix–Hallpike maneuver showed a paroxysmal positional nystagmus typical for canalithiasis of the left PSC. Epley’s reposition procedure was performed: symptoms and nystagmus disappeared after the Wrst session. There was no recurrence during the 12-month follow-up.
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In our series patients were younger than the average general BPPV patients (33.5 vs. 57.3 years) and women are more aVected than men, according with literature [5]. The otoneurological examination in all the patients showed a normal response except from Dix–Hallpike maneuver: the posterior semicircular canal was aVected in all the nine patients. The left ear was aVected in six of the nine patients and the right ear was aVected in three of the nine patients. The Epley maneuver was successful and eliminated vertigo and nystagmus in all patients, in eight of the nine patients after the Wrst session. The remaining patient presented positional nystagmus during the Dix–Hallpike maneuver when evaluated after 1 week, and was therefore successfully submitted to a second Epley maneuver. During the follow-up period (12 months) all patients pursued the habitual sport exercising (after an initial refrain period of 4 weeks) without restrictions of any kind. Four patients (Table 1) showed a recurrence of the BPPV in the same side and semicircular canal after an intense repeated period of the same activity. They were all successfully treated again by a single Epley repositioning procedure. None of the patients had a past or present history of hearing loss, CNS or general health problems. All patients were in good physical condition and regularly attended the sport activity described in Table 1. All these patients complained of acute onset positional rotatory vertigo and nausea arising after a particularly intense period of an otherwise habitual sport activity (2–3 times per week).
Discussion Recently BPPV during intensive mountain biking that generated repeated major vibratory impact was described [12] and also it has been stated that swimming may be causative of BPPV due to rapid head movements during swimming [13]: frequent vibratory impacts and repeated acceleration– deceleration events during intensive oV-road biking as well as rapid head movements during swimming might generate displacement and/or dislocation of otoconia from the otolithic organs, inducing the typical symptoms of BPPV. DiVerently from mountain biking in the presented cases of BPPV following intense physical activity (in otherwise healthy young subjects) there are some conditions that could induce otoconia detachment and displacement in the absence of major head acceleration: minor vibratory movement may be present in heavy aerobics, jogging, marathon, aquarobics, dolphin swimming, with vertical repeated acceleration events of a minor degree; frequent repetition of minor traumatism at each session of long-standing habitual exercising (2–3 times per week) is to be expected in our cases.
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The main upright position of the head during these kinds of sport exercises described would likely cause the detached otoconia to migrate preferably in the posterior (PSC) rather than the LSC. The PSC inlet is anatomically more inferior than LSC inlet: this condition makes it easier for the freeXoating otoconia (subjected to the vertical acceleration during the sport activities described) to be displaced inferiorly towards the PSC inlet. This might explain the PSC involvement in all of our cases. Similar to that described by Aksoy et al. [13], in our patients rapid head movements during sport activities may cause otoconia dislodgement from the macula to the posterior semicircular canals. Physical–emotional distress [17] may be expected during prolonged aerobic physical activity with acute anaerobic surges during the maximum eVort episodes. The Epley repositioning maneuver seems to be able to relieve the BPPV symptoms in all patients: both at the Wrst episode and (in 4 patients) that showed a recurrence within a year after new intense exercising. In conclusion, BPPV due to intense physical activity is a rare condition (2.1% in these series of BPPV) and it may be caused by repeated vibratory vertical accelerations of a minor degree which may be associated with metabolic variations during exercising. These conditions seem to lead mostly to posterior semicircular canal lithiasis. Recurrence of BPPV is anyway possible despite initial successful treatment with CRP after new exercising. Further investigation is necessary to clarify the exact pathogenetic mechanisms in these cases. ConXict of interest interest.
The authors declare that they have no conXict of
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