Benign Proximal Positional Vertigo (BPPV)

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54 Terms

1
•**B**ENIGN

•**P**AROXYSMAL

•**P**OSITIONAL

•**V**ERTIGO

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

<p><mark data-color="red">What does BPPV stand for?</mark></p><ul><li><p>B</p><ul><li><p>doesn’t cause further illness, not life-threatening</p></li></ul></li><li><p>P</p><ul><li><p>sudden and intense episodes</p></li></ul></li><li><p>P</p><ul><li><p>symptoms are triggered by changes in body position</p></li></ul></li><li><p>V</p><ul><li><p>false sense of you or your environment moving</p></li></ul></li></ul>
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peripheral vs central
________ vestibular disorder (inner ear) vs. ________ vestibular disorder (brainstem…)
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endolymph
free-floating particles in the ________ of the semicircular canals (SSC)
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20 to 25
__% to __% of all vertigo is due to BPPV, most frequent cause of vertigo
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otolith

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

  • Inner ear

  • SSC

  • ______ organs

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11 to 64
____ to ____ per 100,000
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2\.4%
Lifetime prevalence =
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54
Mean age at onset ____ years

\[11 to 84 is the documented range\]

* 50-70 is most common
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64%
_____ women
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bilateral
Most likely to be ________

\[95%\]
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15 to 50
__% to __% due to ear trauma or infection.
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Episodic dizziness

Which is more common with BPPV:

  • Persistent dizziness

  • Episodic dizziness

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rotational
Symptoms are often elicited by _______ movement of head rather than final position of head.
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bone density
Pt’s with recurrent BPPV tend to have lower____ _____ scores

\[no evidence that treatment of osteoporosis impacts recurrent BPPV\]
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Symptoms
  • dizziness

  • vertigo

  • lightheadedness

  • imbalance/disequilibrium

  • nausea

  • postural instability

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Dizziness

Vertigo

Lightheadedness

Imbalance/disequilibrium

Postural instability

Nausea
==BPPV Symptoms:==

DeVine LIP Ninjas

(DVLIPN)
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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]

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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

<p><mark data-color="red">B</mark></p><ul><li><p>Displacement of otoconia causing them to be free-floating in a semicircular canal</p></li><li><p><mark data-color="red">Otoconia migrating into SSC</mark></p></li><li><p><strong>Most common form of BPPV</strong></p></li><li><p>Nystagmus:</p><ul><li><p>Later onset (10-40 seconds)</p></li><li><p>A shorter duration of nystagmus will be seen</p></li></ul></li></ul>
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posterior

90
Canalithiasis most commonly occurs in the _____ canal __(______%)

* sends false signals to brain with head movement
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Canalithiasis
Later onset nystagmus with a short duration occurs with ______
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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

<p><mark data-color="red">A</mark></p><ul><li><p><strong>Rare</strong> form of BPPV</p></li><li><p>Displacement of otoconia causing them to attach to the <strong>cupula in a semicircular canal</strong></p></li><li><p>Nystagmus:</p><ul><li><p>Immediate onset and longer duration of nystagmus will be seen</p></li></ul></li></ul>
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Cupulothiasis
Nystagmus with immediate onset and long duration is associated with ______
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Posterior Canal—90%
  • Canalithiasis and cupulothiasis are causative factors

  • Down side ear is affected during Dix-Hallpike

  • Geotropic (beating toward the earth) rotary nystagmus

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Anterior Canal—4%
  • Up facing ear is provoked during Dix-Hallpike

  • Ageotropic (beating away from earth)

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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)

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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

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Diagnostics
Vestibular case history

Videonystagmography (VNG)

Dix-Hallpike
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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

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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

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Positive
______ Dix-Hallpike with the presence/recording of a burst of nystagmus.
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VNG
  • Can help with detecting presence and timing of nystagmus

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

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Infrared nystagmography
Torsional eye movement can be detected directly
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Posturography
Often abnormal but follow no predictable or diagnostic pattern
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Audiogram
  • often normal

  • cochlea not affected

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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).

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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)

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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

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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.

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Watchful waiting
  • Benign so can resolve on its own

  • Or over weeks or months

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Vestibulo suppressant medication
  • provides minimal relief to some patients

  • does not stop vertigo

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Canalith repositioning
  • first choice in treatment

  • cure rate of approximately 80%

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Vestibular Rehabilitation Therapy (VRT)
  • desensitizes balance system to movements that provoke symptoms

  • exercises may increase symptoms at first but will diminish later

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30 sec to 2 min

Each position in a manuerver is held for _________

Maneuvers:

  • Epley maneuver

  • Semont liberatory maneuver

  • Brandt-Daroff exercises

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

  • Patients with posterior, anterior, and horizontal canalithiasis

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Semont liberatory maneuver
  • Patients with anterior and posterior cupulolithiasis

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

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Brandt-Daroff exercises
  • Patients with horizontal cupulolithiasis

  • Use when side of BPPV is unclear

  • 95% success rate

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Surgical Tx
Posterior canal plugging

Singular nerve section
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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

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Singular nerve section
Alternative to plugging
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75
____% recovery rate in BPPV more than 6 months
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97
____% recovered when sought treatment within one week
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33
____% of patients will have a recurrence in the first year after treatment
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50
____% will have recurrence within 5 years
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