Benign Paroxysmal Positional Vertigo

Dr. Deepa Shivnani

BPPV• Dix and Hallpike 1952 – specific characteristics• Vertigo• Rotatory nystagmus• Precipitated by head movement• Latency of 1 - 5 seconds• Accompanying nausea• Fatigable in 15-30 seconds• Adaptable

Dix MR, Hallpike CS. Pathology, symptoms and diagnosis of certain disorders of the vestibular system. Proc R Soc Med.1952;45:341-354

C.S Hallpike

Definition

• Benign paroxysmal positional vertigo (BPPV) is a disorder of the inner ear characterized by episodes of vertigo triggered by changes in head position.

• BPPV is thought to be caused by the presence of endo lymphatic debris in one or more semi-circular canals

• BPPV is termed “benign” because it is a naturally resolving condition

• The average time to resolution of vertigo has been observed to be 13 days, and maximum time was about 35 days

• Despite its favorable prognosis, BPPV is not an entirely benign condition, especially in the elderly, in whom it is often unrecognized and can lead to falls

• The posterior semicircular canal is involved in approximately 94% of cases

• The lateral canal BPPV is next commonWas first described by Cipparrone and McClureTwo distinct subtypes

Geotropic Apogeotropic

Cipparrone L et al.Nistagmografia e pathologica vestibulare periferica. Milano, Italie: V Giornata Italiana di Nistagmografia Clinica;1985:6-53McMclure JA.Horizontal canal BPPV. J Otolaryngol 1985; 14:30-35

Anterior canal BPPV is very rare

Risk Factors

• 18-39:yoga,running on pavement,working underneath objects such as cars,ceiling painters,aerobic exercises,jogging,running on treadmill and swimming

• >40;head trauma,ear disorders(vestibular neuritis or labyrinthitis)

• Certain positions are more likely to provoke vertigo;lying back in bed,arising quickly,looking up,reclining for dental or hair treatments

pathophysiology

• Caused by otoconia that falls in to the PSC or LSC after detaching from the utricle

• Reason for detachment:increased age/trauma and infections

• Schuknecht :basophillic deposits on the cupula of the PSC causes BPPV

• Dix and hallpike :1952/head manuover to produce the ipsidirectional torsional nystagmus used to identify BPPV

Pathophysiology

Cupulolithiasis• Schuknecht first described

cupulolithiasis

• Could not explain Adaptability Fatiguability

Schuknecht HF. Cupulolithiasis. Arch Otolaryngol 1969;90:765-778

Canalolithiasis• McClure and Parnes

described canalolithiasis

McClure JA et al. The mechanics of benign paroxysmal vertigo. J Otolaryngol 1979;8:151-158Parnes LS et al. Particle repositioning maneuver for benign paroxymal postional vertigo. Ann Otol Rhinol Laryngol 1993;102:325-331

• Self Limiting Disorder• Resolves by itself within a few weeks to few

months in most cases• BPPV of PSC typically characterised by

torsional nystagmus which has a duration of less than one minute

• Always peripheral in origin

Nystagmus

• Latency – 5s to 20s• Accompanied by sense of vertigo• Gradual decrease in intensity (15s to 40s)• Beats towards the undermost ear and is

direction-fixed• Fatigable on repetition

Movement of Otolith

Flow of Endolymph

Deflection of cupula in the

PSC

Excitation of Vestibular

Nerve

Stimulation of Maculo spinal

reflex

Maculo-Ocular Reflex

Vertigo

Nystagmus

Positional TestS/N Patient Sitting up S/N Patient Lying Down

1 Head Straight Ahead 1 Head Straight

2 Head Extended 2 Head Hanging

3 Head right side down 3 Head right side down

4 Head left side down 4 Head left side down

5 Head Flexed 5 Head 50 Deg below horizontal & 45 Deg turned to the left

6 Head 30 Deg below horizontal & 45 Deg turned to the right

Positioning tests

• Identify the canal involvedDix-Hallpike testLateral position

Geotropic Apogeotropic

BPPV Manoeuvres

S/N BPPV Variant Management

1 Posterior Canalolithiasis 1. Epley's manoeuvre

2 Posterior Cupololithiasis1. Semont's Liberatory manoeuvre2. Brand daroff’s Exercise

3Horizontal Canalolithiasis(Geotropic)

1. 360 Deg barbecue roll2. Gufoni’s manoeuvre

4Horizontal Cupololithiasis (Apogeotropic)

1. Modified Gufoni ‘s manoeuvre

2. Modified Brand daroff’s Exercise

5 Anterior Canal Cupololithiasis

1. Reverse Epley's manoeuvre2. Reverse Semont's (Liberatory) manoeuvre3. Crevitz manoeuvre

BPPV Variant

Test Direction of nystagmus

Duration of nystagmus

Treatment of choice

Posterior canalolithiasis

Dix-Hallpike test

Upbeat torsional-towards affected side

5-45 sec Epley’s maneuver

Dix-Hallpike Test

Epley’s Maneuver

BPPV Variant Test Direction of nystagmus

Duration of nystagmus

Treatment of choice

Posterior cupulolithiasis

Dix-Hallpike test

Upbeat torsional -towards affected side

Persistant >1min

Semont liberatory maneuver;

Brandt Daroff exercises

Semont’s Maneuver

Brandt-Daroff Exercises

BPPV Variant Test Direction of nystagmus

Duration of nystagmus

Treatment of choice

Horizontal canalolithiasis ( geotropic)

Roll test Horizontal towards the ground

Sec to min 360 deg barbecue roll

Gufoni Maneuver

Roll Test

Barbecue Maneuver

Gufoni Maneuver

BPPV Variant Test Direction of nystagmus

Duration of nystagmus

Treatment of choice

Horizontal cupulolithiasis (apogeotropic)

Roll test Horizontal away from the ground, more severe on the opposite side

Sec to min Modified Gufoni’s maneuver

Modified Brandt-Daroff exercises

Modified Gufoni Maneuver

Modified Brandt-Daroff Exercises

BPPV Variant

Test Direction of nystagmus

Duration of nystagmus

Treatment of choice

Anterior canal Cupulolithiasis

Dix Hallpike test

Head hanging Test

Vertical downbeating nystagmus

Sec to min Reverse Epley’s Maneuver

Reverse Semont’s Maneuver

Crevitz Maneuver

Dix Hallpike test

Head Hanging Test

Crevitz Maneuver

Treatment efficacy

• Patient has relief OR• Dix-Hallpike test negative• Spontaneous remission in 6-12 months• Recurrence in 15-45% in one year

Role of post-maneuver restrictions

• Not to lie down flat.(45 degree head up)• Not to bend over, or look up or look down• Avoid lying down on the affected side for a week• Is it really necessary?

Cakir et al(2006). Efficacy of postural restrictions in treating benign paroxysmal positional vertigo. Arch OHNS, 132,5, 501-505.No more postural restrictions in posterior canal benign paroxysmal positional vertigo. Otology & Neurotology, 2008;29:706-709.

Summary • BPPV :most common type of peripheral

vertigo• Aggrevates with head movements /positional

changes• Associated with nause /vomitting and

classical torsional (psc) or horizontal (lsc) nystagmus

• Diagnosis is by history and positional /positioning testing

cont……….• Management:different manuever for different

types of BPPV• MEDICAL MANAGEMENT :not useful• Surgical management :singular neurectomy

/plugging of PSC• Usually resolves by its own.

THANK YOU……

ANY QUESTION?????