BBPV Flashcards
(BPPV)
Benign Paroxysmal Positional Vertigo Assessment and Treatment (BPPV)
- Single most common cause of dizziness in adults
- Screen everyone if you can – unless they are irritable
How does BPPV Occur?
- Mechanical problem – hardened otoconia dislodge from the utricle and “float” into semi-circular canals
- Otoconia = calcium carbonate crystals
Why Does BPPV Occur?
- Dislodgement of otoconia normally occurs as a result of damage to the utricle/saccule
Possible Mechanisms: - Recent head injury is the most common cause in people under 50
- Vestibular neuritis
- Other disorders of the ear
- Degeneration with age
- No specific cause
Types of BPPV
• Canalithiasis = otoconia is freely mobile in the canal
o Dizziness typically lasts less than a minute
• Cupulolithiasis = otoconia adhere to the cupula
o Dizziness typically lasts more than a minute but may eventually fatigue
Which Canal?
The 3 semi-circular canals are stimulated by different head positions:
• Posterior SCC = extension/rotation (*most common)
• Anterior SCC = flexion/rotation (**least common)
• Horizontal SCC = rotation/rolling
Typical BPPV Symptoms
• Brief episodes of vertigo o Typically lasting < 1 min • Imbalance • Motion sensitivity • Nausea • Occasionally light-headedness • May experience short bursts of giddiness
• Almost always brought on by a change of head position with respect to gravity: o Lying down in bed o Getting up in bed o Rolling over o Bending over o Looking up NB. Should not Have any neurological signs.
Patient Interview
You should have a clear idea from the history as to whether the patient has BPPV:
• True vertigo – spinning
• Brief episodes
• Positional – consider classic provoking positions (can indicate side, but not always)
Diagnostic Tests
3 Basic Manoeuvres to Assess for and Diagnose BPPV
1. Dix-Hallpike Test
2. Side-Lying Test
3. Roll Test
+/- Bow and Lean
Treating BPPV
Treatment is dictated by:
• Proper identification of the involved canal
• Determination of the type of BPPV
Diagnosing BPPV of Posterior and Anterior Canals During Positional Testing:
• (1) Direction of the nystagmus will tell you which canal is involved
• (2) Duration of symptoms will tell you the type of BPPV
Dix-Hallpike Test
ASK IF HAVE ANY CERVICAL PROBLEMS
Tests posterior and anterior canal pairs.
- Patient sits with head turned 45 to one side
- Then moved quickly backward so that the head is extended over the end of the table (30 below horizon)
- look for nystagmus and ask if vertigo then slowly bring back up with head still tilted to 45 degrees
- Performed to both right and left sides
Positive Test: Canalithiasis Variant
- Latency of 2-10 sec after the head is moved into the position and gradual reduction of vertigo and nystagmus (duration < 60 sec = canalithiasis)
- Immediate onset of nystagmus and vertigo after the head is moved into position (sustained duration > 60 sec = cupulolithiasis)
- Characteristic torsional nystagmus
- Reversal of nystagmus with vertigo on sitting up
- Fatigued response with repeated positioning
Side-Lying Test
Tests for both anterior and posterior canal pairs.
- Simply an easier test without using edge of bed for easier handling
- Can be done for those who are anxious or do not tolerate cervical extension
- Patient sits on the side of the bed with the head rotated 45’ to one side
- Then quickly brought down on their side opposite to the direction the head is turned
- Watch for nystagmus and onset of vertigo
- The patient is then brought back to sitting with the head still turned 45 and symptoms are checked
- Repeat to the other side
NB. Diagnosis of BPPV canal and type with same symptom and nystagmus pattern as Dix-Hallpike
ROSE TEST/DEEP HEAD HANG
Deep Head hang
In some cases of posterior / anterior BPPV, you will need to comfirm what you saw on the HPD from the nystagmus.
The optimal test is a Deep head hang if the patient is able to tolerate this test. The patient is laid back quickly supine
without any head rotation till the top of the head is pointing to the floor (eg neck at 90degrees). Movements are
performed actively with the therapist guiding and then fully supporting the head. Note the direction of the nystagmus
and the duration. Remember the posterior canal will produce obvious torsion while the anterior is less robust in
production of torsion.
30-45˚ ext for 30 > quickly tuck chin and hold for 30 > move to sitting with chin tucked, hold for 30
Canalithiasis vs. Cupulolithiasis
Vertical canals: posterior and anterior pairs Canalithiasis • Delay in onset of symptoms • Presence of nystagmus • Duration < 1 min • Most common type
Cupulolithiasis • Immediate onset of symptoms • Presence of nystagmus • Duration > 1 min (until fatigue) • Relatively uncommon
- Roll Test – determines cath or cup
Diagnostic test for horizontal SCC:
- Patient lies supine with head flexed to 30
- The head is quickly rolled to one side
o Watch: for nystagmus and reports of vertigo
- The head is then slowly returned to the midline
- Test is repeated to the other side
- If horizontal canal BPPV, vertigo and nystagmus will occur on both sides
NB. Roll body if you cannot turn the head.
Diagnosing Horizontal Canal BPPV
The direction of the nystagmus is dependent on whether it is canalithiasis or cupulolithiasis:
Canalithiasis – may fatigue and is be geotrophic (always beat to the ground)
(Left roll test = left beating nystagmus)
Cupulolithiasis – nystagmus persists and is apogeotrophic (up is cup)
(Left roll test = right beating nystagmus)
Horizontal Canal BPPV:
Geotrophic nystagmus – during right and left roll test = canalithiasis
Apogeotrophic nystagmus – during right and left roll test = cupulolithiasis
NB. Side with crystals is the side with the symptoms
NB2. Put the affected canal down first (for treatment)
nystagmus will be higher when the patient is rolled towards the affected ear (Baloh et al., 1993) for HC canalithiasis; the opposite is expected in cases of HC cupulolithiasis; nystagmus less intense to the affected
To determine the affected ear of Horizontal Canal BPPV:
Canalithiasis
- Geotrophic:
o When you bow down the eyes will beat to the side of the crystals
o Looking up the eyes will beat away from the crystals
o *Most symptomatic side is probably affected
Cupulolithiasis
- Apogeotrophic:
o When you bow down the eyes will beat away from the side of the crystals
o Looking up the eyes will beat towards the crystals
o *Least symptomatic side is probably affected
Treatment Options – Canalithiasis
¬ Canalith Repositioning Manoeuvres (CRM)
¬ Brandt-Daroff Exercises
CRM For Posterior SCC
Posterior and Anterior Canal:
¬ Epley (Modified Semont) (canalithiasis)
¬ Semont Liberatory Manoeuvre (cupulolithiasis*)
