Paroxysmal positioning dizziness (VPP)


                             It is one of the  most frequent symptoms among balance disorders. Although known for many decades it is often still not recognized, mainly due to an apparent relationship with cervical factors.
It consists of short paroxysmal attacks of objective roundabout vertigo, triggered by changes in position, without auditory procession and generally accompanied by an intense neurovegetative reaction (nausea, vomiting, sweating, etc.).
The critical movements    most frequently reported by patients are: the backflexion of the head (look upwards), the flexion of the head (fastening your shoes, brushing your teeth or face, collecting objects), getting out of bed, lying down, taking a side slope, sexual  activity.
A clear lateralita is  often reported. Vertigo rises rapidly after movement, is accompanied or is sometimes replaced by sensations of overturning or sinking, tends to run out in a few seconds, recurs with each critical movement while there is a certain tendency to reduce intensity if the movements  are re-performed in rapid temporal succession.
Crises can be numerous during the day, limited almost only in the morning when waking up or in the evening at bedtime, probably depending on the patient’s lifestyle habits and, therefore, the movements made during the day.
In about 40-50 percent of cases, there is a feeling of instableness  or chinetosis.
Many times  there is a muscular cervical headache, with a reactive armor type, which often directs the patient or doctor precisely towards hypothetical cervical etiopathogenetic mechanisms. In  fact, it is an anti-critical armour,  whichis therefore the consequence and not the cause of vertigo.
The duration of the critical period varies  greatly, from a few hours to several months, sometimes years. Even after disappearing (hence the term “benign” often included in the definition) VPP often tends to recur in the following months or years.
Only in rare cases does it seem that it can persist unchanged over time (disabling  positional  vertigo). The characteristics of this type of vertigo cause a considerable degree of disability in the patient’s daily life and social relationships and are often responsible for anxious and
real phobias towards some potentially critical situations.
In the vast majority of cases, these are idiopathic forms, which are forms whose cause cannot be understood.
In other cases  there is a clear traumatic antecedent (head trauma, cervical sprain with “whiplash” mechanism),  otosurgery); sometimes   a causal relationship with various types of labyrinthine microangiopathy  is strongly suspected.
Time relationships with stressful events (bereavements, family or work problems), general anesthesia, pharmacological therapies (especially  aminoglycosisantibiotics, cortisonics, chemotherapy) or physical (violent cervical manipulations, radiotherapy) are sometimes reported by patients.
In the case of drugs or radiotherapy  it is possible to evoke a mechanism of damage to otolitic macular structures, while in other cases the possible pathogenic mechanism  is  currently obscure.
The various etiologies seem to be able to act with a fundamental pathogenic mechanism: the creation of endolabirintic foreign bodies  capable of provoking abnormal endolabirintic  movements (hypothesis of the so-called canalolithiasis)or of coming directly intocontact with the ampollar ridges of the various semicircular channels (hypothesis of so-called cupulolysis),generating aviolent paroxysmal ocular nystagmus.
It is important to diagnose  cupulo-channelolithase  early because this pathology responds very satisfactorily to therapy with so-called liberating orrepositioning maneuvers of otolites.
These are manoeuvres that in a very small number of sessions (usually from 1 to 4) allow the total disappearance of symptomatology in a percentage of cases dependent on the operator’s experience but still habitually more than 80-90%.

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