Benign paroxysmal positional vertigo

Question 1

Definition

Answer 1

Vestibular disorder
Migration of free floating endolymph canalith particles
Sudden, short liver, positional

Question 2

Pathophysiology

Answer 2

Abnormal signal arising from a canal leads to the misperception of movement (vertigo) and nystagmus of the eye in the plane of that canal.

free-floating endolymph particles–>canaliths (which are migrate into the semicircular canals over time via natural head movements. The canalith particles are denser than the surrounding endolymph fluid and therefore respond to gravity. These canaliths tend to settle into the posterior semicircular canal in particular.

Consequently, specific head movements in the plane of the affected canal, combined with head movements that align the affected canal more vertically, allow canalith particles to gravitate downwards, causing a hydrodynamic drag force that induces an endolymph current and deflects the cupula, thereby stimulating the hair cells.

Question 3

Risk factors

Answer 3

Age +
Female
Head trauma
Vestibular neuronitis
Labrynthitis
Migraines
Inner ear surgery
Meniere's

Question 4

Key diagnostic features (11)

Answer 4

presence of risk factors (common)
specific provoking positions (common)
brief duration of vertigo (common)
episodic vertigo (common)
severe episodes of vertigo (common)
sudden onset of vertigo (common)
nausea, imbalance, and lightheadedness (common)
absence of associated neurological or otological symptoms (common)
normal neurological examination (common)
positive Dix-Hallpike manoeuvre or positive supine lateral head turn (common)
normal otological examination (common)

Question 5

Tests to perform

Answer 5

Dix hallpike

Supine roll

Question 6

Physical treatments of motion induced vertigo

Answer 6

Cawthorne cooksey->at home
Semont
Epley
Brandt-Daroff

Question 7

Cawthorne-cooksey treatment

Answer 7

Treatment when recovering from neuritis
Sitting
1. Eye movements—at first slowly, then quickly:
up and down
from side to side
focus on finger with arm extended and slowly move finger towards face until vision starts to blur.
2. Head movements—at first slowly, then quickly (later with eyes closed):
bend forward and backward
turn from side to side.
3. Bend forward and pick up objects from the ground.
Standing
1. Follow steps 1 to 3 described above while standing.
2. Change from sitting to standing position with eyes open and shut.
3. Throw a small ball from hand to hand (above eye level).
4. Change from sitting to standing position and make a full turn in between.
Moving about
1. Circle around a centre person who will throw a ball back and forth.
2. Walk across a room with eyes open and then closed.
3. Walk up and down a slope with eyes open and then closed.
4. Walk up and down steps with eyes open and then closed.
5. Any game involving bending, stretching and aiming such as tennis, bowls or basketball.

Question 8

Should vestibular suppressant medication be used in uncompensated peripheral vestibular lesion

Answer 8

No

May impede compensatory process

Question 9

Semont

Answer 9

For the treatment of right-sided disease (reverse head position for left-sided disease):
A. Position patient on edge of bed with head turned 45 degrees to left.
B. While maintaining this head position, tip patient to right side (also an alternative method for performing the Hallpike manoeuvre) and wait 1 minute.
C. Move patient quickly through 180 degrees (maintaining original head position), wait another minute and then sit patient up slowly.

Question 10

Epley

Answer 10

For the treatment of right-sided disease (reverse head position for left-sided disease):
A. Position patient on bed with head slightly extended and turned 45 degrees to right.
B. Position patient with head over a pillow placed at shoulder level (as for a normal Hallpike manoeuvre) and wait 1 minute.
C. Turn head through 90 degrees to left and wait another minute.
D. Turn head through a further 90 degrees to left, while patient rolls onto left side and wait another minute.
E. Sit patient up slowly.

Question 11

Management

Answer 11

1. Patient education and reassurance->not lifethreatening, good prognosis, 3 weeks duration typically, highly treatable with single particle repositioning manouvre, but recurrences can happen
2. Repositioning- epley, semont
3. If fails->vestibular rehabilitation, specialised
4. Medications not generally effective

Question 12

Contraindications to repositioning

Answer 12

severe cervical disease, unstable cardiovascular disease, suspected vertebrobasilar disease, and high-grade carotid stenosis.