Benign Paroxysmal Positional Vertigo

(BPPV)

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Definition

-  Paroxysmal attacks of vertigo +/- nystagmus provoked by head position caused by peripheral vestibular pathology

 

Features

-  Most common form of positional vertigo

-  Lifetime prevalence 2.4%

-  x7 incidence >60yrs old compared to 18-39yrs

-  Women > men

 

Cause

-  Calcium debris within semicircular canal (canalithiasis)

-  Likely loose totconia within utricle

-  Mechanism

-  Idiopathic 35%

-  Head trauma 15%: may be minor

-  Residual effect from vestibular path

-  Menieres disease 30%

-  Vestibular neuronitis

-  Ear surgery

-  Inner ear ischaemia

-   ? link w Temporal Arteritis

-   ? link w vascular risk factors

 

Associated S/S

-  Vertigo

-  Sensation of head spinning when head shifts

-  Recurrent episodes lasting <1min

-  Periodically for weeks to months

-  Mean duration 2 weeks

-  Provoked by specific head movements

-  Looking up whilst standing or sitting

-  Lying down or getting up from bed

-  Rolling over in bed

-  Often sudden spontaneous remission

-  +/- nausea & vomiting

-  Usually no neuro defecit

-  50% describe imbalance between attacks

 

Types

-  Posterior Canal BPPV

-  Most common type

-  Dx by Hallpike manouvre

-  Nystagmus + vertigo appear by seconds & lasts <30sec

-  Upward & torsional nystagmus

-  Nystagmus recurs in opposite direction once intial nystagmus ceased & pt sits up

-  Demonstrates fatigability (intensity & duration) by repeated manouvres on same side

-  Anterior Canal BPPV

-  AKA Superior Canal BPPV

-  Downward & torsional nystagmus

-  Similar latency, duration & fatigability of Posterior Canal BPPV

-  Horizontal Canal BPPV

-  Provoked by turning head whilst lying down

-  Horizontal nystagmus toward floor (when supine) after 1-8 seconds when effected ear down

-  Lasts approx 1min

-  After several sec of inactivity reverses

-  25% pts also have Posterior Canal BPPV

-  Pure Torsonal BPPV

-  50% pts

-  Posterior & anterior canals effected

 

DDx

-  Central positional vertigo

-  Postional hypotension

-  Migrainous vertigo

-  Chronic unilateral vestibular hypofunction

-  Static positional vertigo

 

Ix

-  Neuro exam

-  If defecit ?central cause not BPPV

-  Dix-Hallpike (Hallpike) manouvre

-  Observation of nystagmus during provocation

-  +/- Electronystagmography

-  Only if pre-existing vestibular disease is suspected

-  +/- Imaging

-  Only if nystagmus does not fit Posterior Canal BPPV

 

Mx

-  Untreated episodes usually spontaneously resolve by days to weeks

-  Recurrence more likely if >40yrs or >3yrs of S/S prior to Mx

-  Particle repositioning manouvres

-  Encourage debris to migrate to exit into utricle cavity

-  May be effective even if nystagmus not seen on exam if clinically suspicious of BPPV

-  6% pts debris migrate into another canal causing variants of BPPV

-  Epley manouvre or Semont manouvre

-  Used for Posterior & Anterior Canal BPPV

-   Not helpful for Horizontal Canal BPPV

-  Success predicted by inspection of nystagmus during second position

-   Reversed nystagmus or no nystagmus suggests reduced/nil efficacy

-  Safe & effective

-  May be repeated if poor response to intial attempt

-  Lempert Roll manouvre

-  Barbeque rotation

-  Used for Horizontal Canal BPPV

-  Self Mx

-  Brandt-Daroff exercise

-  Less effective than particle repositioning

-  Useful if patient respond poorly to Epleys

-  Meds

-  Vestibular suppressants as premedication to particle repositioning manouvres if poor tolerance

-  Surgery

-  Surgical occlusion 90% success rate

-  Suitable for a small number of patients w intractable disease

 

 

 

References

 

Upto Date: Benign Paroxysmal Positional Vertigo: May 2010