“You know those little handheld pinball games?” I asked. Mr. Riccio nodded. “The crystals are like the tiny metal balls in one of those games. Once they’re in the wrong spot, it’s hard to get them back. They roll around every time you move your head and unintentionally set off motion sensors. So your brain gets the wrong information about balance. It thinks you’re moving in one direction when you’re really not. So it overcorrects, and you end up with the spinning sensation.”
He leaned forward and pursed his lips.
“Is there another pill to try?” He sounded tired, a little frustrated.
“Something even better.”
In 1983, John Epley, an otolaryngologist in Portland, Oregon, found that a precise series of guided head movements could rid patients of vertigo by directing the disruptive crystals out of the semicircular canals. Initially the local medical community dismissed his finding. To many physicians, any technique based on a maneuver or manipulation smacks of hocus-pocus. But the treatment was backed up by scientific studies, and by 1992 doctors had come to accept it.
The Epley maneuver is now the standard treatment for BPPV. Because it involves manipulating the head and neck into certain positions, in rare instances it is not recommended for patients with unstable heart disease, severe blockage of the carotid arteries, or neck disease. Otherwise the maneuver is safe and quite effective, relieving vertigo in 80 percent of patients with BPPV.
It was worth a try.
I asked Mr. Riccio to sit on the exam table again. I explained that we needed to position him so he was lying on his back with his head hanging to one side and gently tilted backward. I warned him that the changes in position would momentarily trigger the dizziness, if my suspicion about the cause of his vertigo was correct.
Standing at his side, I said, “Hold my right forearm,” as I braced my left hand on his back. “Now turn your head to the right and keep it turned as you lie down.” I guided him down until he was flat on his back, his head tilted back over the edge, his right ear pointing at the floor.
“Whoa, there it goes,” he said, opening his eyes wide. “That’s the feeling. That’s the one.” As I moved his head into the different positions, I pictured a little pinball game and imagined I was directing the tiny balls—the crystals—back into their designated holes.
After 30 seconds I turned his head gently so his left ear was pointing down. Then I instructed him to keep his head still and to roll over onto his left shoulder, keeping his head angled down to the exam table. Another 30 seconds.
“Now please sit up without changing the position of your head and tell me if you still feel dizzy.” I helped him up.
“Oh yeah, very dizzy.” He braced himself, clutching the edge of the exam table.
We repeated the whole sequence two more times, and by the last time Mr. Riccio sat up, the dizziness was gone. It might come back, I told him, but it would probably be less intense. I printed a diagram showing how he could do a modified version of the Epley maneuver at home, using a pillow under the shoulders to position his head at the correct angle. If he did this a few times a day until the dizziness was gone for 24 hours, it would probably stay away for a while, and in some cases for good.
Two months later he was back for his regular checkup. We walked briskly from the waiting room to my office. He was beaming.
“Doctor, can I give you a hug?” he asked. “You cured me!”
Just call me a pinball wizard.
Anna Reisman is an internist in Woodbridge, Connecticut. The cases described in Vital Signs are real, but names and certain details have been changed.
