Benign Proximal Positional Vertigo (BPPV)

•**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

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 ***

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 ***

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 ***

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