Two types of peripheral vertigo, B.P.P.V. & Meniere's disease merit a special mention.

B.P.P.V.

Barany in 1921 first proposed this disorder & felt that it was related to the otolithic organ.

Dix & Hallpike coined the term B.P.P.V.

Schuknecht reported temporal bone sections showing amorphous basophilic debris on the posterior canal cupula, & thought it to be degenerated otoconia. He referred to this as cupulolithiasis.

Aetiology:

•  Idiopathic: 60%

•  Post-traumatic: 60%

•  Otitis media & post-otologic surgery: 25%

•  VBI.

•  Excessive alcohol consumption.

•  Localized HFN infection.

All of the above dislodge the otoconia from the macula utriculae, & these gravitate to the most dependant part of the labyrinth, the ampulla of the posterior semi-circular canal.

The classic clinical appearance is of intense rotatory vertigo of variable intensity, a few seconds to few minutes in duration, increasing on change of position, which is fatigable, with a tendency to relapse.

There are no neurologic signs, the gait is normal & the caloric test is ambiguous.

The nystagmus is not spontaneous, it is fatigable, & is directed towards the lowermost ear.

Treatment:

Vestibular suppressants.

Cawthorne-Cooksey rehabilitation exercises

Atropine analogues

Gacek's nerve section. (very rarely performed )

Meniere's disease:

It is a disease of the membranous labyrinth characterised by episodic vertigo, fluctuant hearing loss & roaring tinnitus, which has as its pathologic correlate the hydropic distension of the endolymph space.

It is usually associated with vagal symptoms, fullness of the ears & the sufferer is usually normal in between attacks.

Aetiology:

•  Overproduction of the endolymph.

•  Vasospastic theory: Autonomic imbalance in the arterioles of the stria vascularis.

•  Herniation/rupture of the membranous labyrinth.

•  Metabolic disturbances, either local or systemic.

•  Allergy.

•  Thyroid disorders.

This is to be differentiated from Meniere's syndrome, wherein a known etiology exists, & Meniere-like syndrome, wherein there is no fluctuation of hearing or episodic vertigo.

A predominantly cochlear type & a predominantly vestibular type of Meniere's exists.

Lermoyez' syndrome is another variant, characterised by progressively increasing hearing loss & vertigo, followed by vomiting, & then complete recovery.

The initial treatment of Meniere's disease is medical. The following pharmacological groups are used in the initial treatment, either individually, or, more commonly, combined.