Benign Proximal Positional Vertigo (BPPV)

•BENIGN

•PAROXYSMAL

•POSITIONAL

•VERTIGO

What does BPPV stand for?

• B

  • doesn’t cause further illness, not life-threatening

• P

  • sudden and intense episodes

• P

  • symptoms are triggered by changes in body position

• V

  • false sense of you or your environment moving

peripheral vs central

________ vestibular disorder (inner ear) vs. ________ vestibular disorder (brainstem…)

endolymph

free-floating particles in the ________ of the semicircular canals (SSC)

20 to 25

__% to __% of all vertigo is due to BPPV, most frequent cause of vertigo

otolith

Results from damage to the. delicate sensory units of the:

• Inner ear

• SSC

• ______ organs

11 to 64

____ to ____ per 100,000

2.4%

Lifetime prevalence =

54

Mean age at onset ____ years

[11 to 84 is the documented range]

• 50-70 is most common

64%

_____ women

bilateral

Most likely to be ________

[95%]

15 to 50

__% to __% due to ear trauma or infection.

Episodic dizziness

Which is more common with BPPV:

• Persistent dizziness

• Episodic dizziness

rotational

Symptoms are often elicited by _______ movement of head rather than final position of head.

bone density

Pt’s with recurrent BPPV tend to have lower____ _____ scores

[no evidence that treatment of osteoporosis impacts recurrent BPPV]

Symptoms

• dizziness

• vertigo

• lightheadedness

• imbalance/disequilibrium

• nausea

• postural instability

Dizziness

Vertigo

Lightheadedness

Imbalance/disequilibrium

Postural instability

Nausea

BPPV Symptoms:

DeVine LIP Ninjas

(DVLIPN)

Pt complaints

The illusion that you or your environment is moving or spinning.

Occurs with:

• rolls into a lateral position in bed

• gazing upward

• bending forward

• fast neck turn

[Most common symptom]

Canalithiasis

B

• Displacement of otoconia causing them to be free-floating in a semicircular canal

• Otoconia migrating into SSC

• Most common form of BPPV

• Nystagmus:

  • Later onset (10-40 seconds)

  • A shorter duration of nystagmus will be seen

posterior

90

Canalithiasis most commonly occurs in the _____ canal (____%)

• sends false signals to brain with head movement

Canalithiasis

Later onset nystagmus with a short duration occurs with ______

Cupulothiasis

A

• Rare form of BPPV

• Displacement of otoconia causing them to attach to the cupula in a semicircular canal

• Nystagmus:

  • Immediate onset and longer duration of nystagmus will be seen

Cupulothiasis

Nystagmus with immediate onset and long duration is associated with ______

Posterior Canal—90%

• Canalithiasis and cupulothiasis are causative factors

• Down side ear is affected during Dix-Hallpike

• Geotropic (beating toward the earth) rotary nystagmus

Anterior Canal—4%

• Up facing ear is provoked during Dix-Hallpike

• Ageotropic (beating away from earth)

Horizontal Canal -- 6%

• Best provoked by having patient lay flat in supine position and then move head quickly to the ear-down position

  • (right and left)

• Horizontal geotropic nystagmus is observed while the patient is vertiginous (suffering from vertigo)

Head trauma

Labyrinthitis

Iatrogenic

Common causes of BPPV:

• ______ ______ (most common cause of BPPV in people under 50)

• Degeneration of vestibular system (more common as people age)

• Viral

• ________

• Prolonged Bed Rest

• ________:  following surgery or ototoxic medications

Diagnostics

Vestibular case history

Videonystagmography (VNG)

Dix-Hallpike

Videonystagmography (VNG

A battery of eye-movement tests given to people with dizziness, vertigo and/or balance disorders

• Identify or rule out other vestibular dysfunction or neurological problems

• Measures nystagmus (involuntary side-to-side eye movement) which helps distinguish type of BPPV

Dix-Hallpike

• Standard clinical test for BPPV

• Helps reveal which canal is involved

  • Differentiate canalithiasis or cupulolithiasis

• Steps for Pt:

  • Turn head 45 degrees toward presumed affected side

  • Clinician rapidly brings pt from upright to supine position with head hanging off table

  • Particles will drift into posterior canal—nystagmus occurs within 10 seconds and fatigues within 30 seconds

  • Pt is returned to upright position

Positive

______ Dix-Hallpike with the presence/recording of a burst of nystagmus.

VNG

• Can help with detecting presence and timing of nystagmus

• Caloric test is abnormal in 32 to 47% (Valente, p652)

Infrared nystagmography

Torsional eye movement can be detected directly

Posturography

Often abnormal but follow no predictable or diagnostic pattern

Audiogram

• often normal

• cochlea not affected

Canalolithiasis of the posterior canal

(pc-BPPV)

• Recurrent attacks1 of positional vertigo or positional dizziness provoked by lying down or turning over in the supine position.

  • Duration under < 1 min

• Positional nystagmus elicited after a latency of one or few seconds by the Dix-Hallpike maneuver or side-lying maneuver (Semont diagnostic maneuver).

  • The nystagmus is a combination of torsional nystagmus with the upper pole of the eyes beating toward the lower ear combined with vertical nystagmus beating upward (toward the forehead).

Canalolithiasis of the horizontal canal (hc-BPPV)

• Recurrent attacks of positional vertigo or positional dizziness provoked by lying down or turning over in the supine position.

• Duration < 1 minute

• Positional nystagmus elicited after a brief latency or no latency by the supine roll test

  • Beating horizontally toward the undermost ear, with the head turned to either side (geotropic direction changing nystagmus)

2.3. Cupulolithiasis of the horizontal canal (hc-BPPV-cu)

• Recurrent attacks of positional vertigo or positional dizziness provoked by lying down or turning over in the supine position.

• Positional nystagmus elicited after a brief latency or no latency by the supine roll test,

  • Beating horizontally toward the uppermost ear with the head turned to either side (apogeotropic (ageotropic) direction changing  nystagmus)

  • Lasting > 1 min

Probable benign paroxysmal positional vertigo, spontaneously resolved

• Recurrent attacks of positional vertigo or positional dizziness provoked by lying down or turning over in the supine position.

• Duration of attacks < 1 min.

• No observable nystagmus and no vertigo with any positional maneuver.

Watchful waiting

• Benign so can resolve on its own

• Or over weeks or months

Vestibulo suppressant medication

• provides minimal relief to some patients

• does not stop vertigo

Canalith repositioning

• first choice in treatment

• cure rate of approximately 80%

Vestibular Rehabilitation Therapy (VRT)

• desensitizes balance system to movements that provoke symptoms

• exercises may increase symptoms at first but will diminish later

30 sec to 2 min

Each position in a manuerver is held for _________

Maneuvers:

• Epley maneuver

• Semont liberatory maneuver

• Brandt-Daroff exercises

Epley maneuver

• Relocate debris from SSC into the vestibule through a sequence of head movements.

• Patients with posterior, anterior, and horizontal canalithiasis

Semont liberatory maneuver

• Patients with anterior and posterior cupulolithiasis

• Not common in U.S ~90% success rate after 4 sessions

Brandt-Daroff exercises

• Patients with horizontal cupulolithiasis

• Use when side of BPPV is unclear

• 95% success rate

Surgical Tx

Posterior canal plugging

Singular nerve section

Posterior canal plugging

• Only indicated for patients when both office maneuvers and home exercises were ineffective

• Block posterior canal without affecting functions of other canals or parts of the ear

• 3% risk of unilateral hearing loss 85-90% success rate

Singular nerve section

Alternative to plugging

75

____% recovery rate in BPPV more than 6 months

97

____% recovered when sought treatment within one week

33

____% of patients will have a recurrence in the first year after treatment

50

____% will have recurrence within 5 years