Benign Paroxysmal Positional Vertigo

Question 1

What is benign paroxysmal positional vertigo (BPPV)?

Answer 1

Benign paroxysmal positional vertigo (BPPV) is a peripheral vestibular disorder that manifests as sudden, short-lived episodes of vertigo elicited by specific head movements. BPPV is one of the most common causes of vertigo.

Question 2

What does a ‘peripheral’ cause of vertigo refer to?

Answer 2

It is a peripheral cause of vertigo, meaning the problem is located in the inner ear rather than the brain.

Question 3

Briefly describe the pathophysiology of BPPV

Answer 3

BPPV is caused by crystals of calcium carbonate called otoconia that become displaced into the semicircular canals. This occurs most often in the posterior semicircular canal. They may be displaced by a viral infection, head trauma, ageing or without a clear cause.

The crystals disrupt the normal flow of endolymph through the canals, confusing the vestibular system. Head movement creates the flow of endolymph in the canals, triggering episodes of vertigo.

Question 4

What are the risk factors for BPPV?

Answer 4

• Increasing age
• Female sex
• Head trauma
• Vestibular neuronitis
• Labyrinthitis
• Migraines
• Inner ear surgery
• Meniere’s disease

Question 5

What are the clinical features of BPPV?

Answer 5

• Specific provoking positions
• Brief duration of vertigo
• Episodic vertigo
• Severe episodes of vertigo
• Nausea, imbalance and lightheadedness

Question 6

How long do vertigo attacks last in BPPV?

Answer 6

A variety of head movements can trigger attacks of vertigo. Symptoms settle after around 20 – 60 seconds, and patients are asymptomatic between attacks. Often episodes occur over several weeks and then resolve but can reoccur weeks or months later.

Question 7

What is the most common trigger for BPPV?

Answer 7

A common trigger is turning over in bed.

Question 8

How does BPPV present on examination?

Answer 8

Absence of associtated neurological or otological symptoms e.g. hearing loss, aural fullness and tinnitus.

Question 9

Does BPPV present with hearing loss or tinnitus?

Answer 9

BPPV does not cause hearing loss or tinnitus.

Question 10

What is used to diagnose BPPV?

Answer 10

Dix-Hallpike manoeuvre

Question 11

Briefly describe the role of the Dix-Hallpike manoeuvre and how it presents in BPPV

Answer 11

The Dix-Hallpike manoeuvre can be used to diagnose BPPV (Dix for Dx – diagnosis). It involves moving the patient’s head in a way that moves endolymph through the semicircular canals and triggers vertigo in patients with BPPV.

In patients with BPPV, the Dix-Hallpike manoeuvre will trigger rotational nystagmus and symptoms of vertigo. The eye will have rotational beats of nystagmus towards the affected ear (clockwise with left ear and anti-clockwise for right ear BPPV).

Question 12

Briefly describe the steps in the Dix-Hallpike manoeuvre

Answer 12

Check the patient can do the manoeuvre safely before performing it, for example, ensuring they have no neck pain or pathology.

To perform the manoeuvre:

1. The patient sits upright on a flat examination couch with their head turned 45 degrees to one side (turned to the right to test the right ear and left to test the left ear)
2. Support the patient’s head to stay in the 45 degree position while rapidly lowering the patient backwards until their head is hanging off the end of the couch, extended 20-30 degrees
3. Hold the patient’s head still, turned 45 degrees to one side and extended 20-30 degrees below the level of the couch
4. Watch the eyes closely for 30-60 seconds, looking for nystagmus
5. Repeat the test with the head turned 45 degrees in the other direction

Question 13

What is used to treat BPPV?

Answer 13

Epley manoeuvre

Question 14

Briefly describe the role of the Epley manoeuvre

Answer 14

The Epley manoeuvre can be used to treat BPPV. The idea is to move the crystals in the semicircular canal into a position that does not disrupt endolymph flow.

Question 15

Briefly describe the steps in the Epley manoeuvre

Answer 15

To perform the manoeuvre:

1. Follow the steps of the Dix-Hallpike manoeuvre, having the patient go from an upright position with their head rotated 45 degrees (to the affected side) down to a lying position with their head extended off the end of the bed, still rotated 45 degrees
2. Rotate the patient’s head 90 degrees past the central position
3. Have the patient roll onto their side so their head rotates a further 90 degrees in the same direction
4. Have the patient sit up sideways with the legs off the side of the couch
5. Position the head in the central position with the neck flexed 45 degrees, with the chin towards the chest
6. At each stage, support the patient’s head in place for 30 seconds and wait for any nystagmus or dizziness to settle

Question 16

What is the role of Brandt-Daroff exercises?

Answer 16

Brandt-Daroff exercises can be performed by the patient at home to improve the symptoms of BPPV. These involve sitting on the end of a bed and lying sideways, from one side to the other, while rotating the head slightly to face the ceiling. The exercises are repeated several times a day until symptoms improve.

Question 17

What are the complications of BPPV?

Answer 17

• Peri- or post-repositioning manoeuvre-related BPPV
• Peri- or post-repositioning manoeuvre-related nausea, emesis, autonomic dysfunction or imbalance
• Falls in older patients
• Road traffic accidents

Question 18

What differentials should be considered for BPPV?

Answer 18

• Meniere’s disease
• Vestibular neuritis
• Labyrinthitis
• Perilymphatic fistula
• Central disorders e.g. migraines and multiple sclerosis