Benign Proximal Positional Vertigo (BPPV)

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

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

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

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

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

• Inner ear

• SSC

• ______ organs

____ to ____ per 100,000

Lifetime prevalence =

Mean age at onset ____ years

[11 to 84 is the documented range]

• 50-70 is most common

_____ women

Most likely to be ________

[95%]

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

Which is more common with BPPV:

• Persistent dizziness

• Episodic dizziness

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

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

[no evidence that treatment of osteoporosis impacts recurrent BPPV]

• dizziness

• vertigo

• lightheadedness

• imbalance/disequilibrium

• nausea

• postural instability

BPPV Symptoms:

DeVine LIP Ninjas

(DVLIPN)

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]

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

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

• sends false signals to brain with head movement

Later onset nystagmus with a short duration occurs with ______

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

Nystagmus with immediate onset and long duration is associated with ______

• Canalithiasis and cupulothiasis are causative factors

• Down side ear is affected during Dix-Hallpike

• Geotropic (beating toward the earth) rotary nystagmus

• Up facing ear is provoked during Dix-Hallpike

• Ageotropic (beating away from earth)

• 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)

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

Vestibular case history

Videonystagmography (VNG)

Dix-Hallpike

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

• 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

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

• Can help with detecting presence and timing of nystagmus

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

Torsional eye movement can be detected directly

Often abnormal but follow no predictable or diagnostic pattern

• often normal

• cochlea not affected

• 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).

• 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)

• 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

• 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.

• Benign so can resolve on its own

• Or over weeks or months

• provides minimal relief to some patients

• does not stop vertigo

• first choice in treatment

• cure rate of approximately 80%

• desensitizes balance system to movements that provoke symptoms

• exercises may increase symptoms at first but will diminish later

Each position in a manuerver is held for _________

Maneuvers:

• Epley maneuver

• Semont liberatory maneuver

• Brandt-Daroff exercises

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

• Patients with posterior, anterior, and horizontal canalithiasis

• Patients with anterior and posterior cupulolithiasis

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

• Patients with horizontal cupulolithiasis

• Use when side of BPPV is unclear

• 95% success rate

Posterior canal plugging

Singular nerve section

• 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

Alternative to plugging

____% recovery rate in BPPV more than 6 months

____% recovered when sought treatment within one week

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

____% will have recurrence within 5 years