Benign Paroxysmal Positional Vertigo

Question 1

Define Benign Paroxysmal Positional Vertigo

Answer 1

Peripheral vestibular disorder that manifests as sudden, short-lived episodes of vertigo and head movements

Question 2

Aetiology Benign Paroxysmal Positional Vertigo

Answer 2

Displacement of otoliths in semi-circular canals

Primary: idiopathic (50-70%)
Secondary:
- Head trauma
- Labyrinthitis
- Migraines
- Vestibular neuronitis
- Meniere’s disease
- Ischaemic processes
- Iatrogenic causes

Question 3

Risk factors Benign Paroxysmal Positional Vertigo

Answer 3

Older age
Female
Head trauma
Vestibular neuronitis
Meunière’s disease
Inner ear surgery
Otitis media
HTN, Hyperlipidaemia, DM
Giant cell arteritis

Question 4

Symptoms of Benign Paroxysmal Positional Vertigo

Answer 4

Vertigo - environment is spinning
- BRIEF - <30s
- sudden onset
- episodic
- specific provoking positions e.g. head turning, household chores
Nausea
Imbalance
Light headedness

Question 5

Signs on examination for Benign Paroxysmal Positional Vertigo

Answer 5

Normal neuro exam
During an episode - nystagmus

Question 6

Investigations for Benign Paroxysmal Positional Vertigo

Answer 6

Dix-hallpike manoeuvre
Supine lateral head turns

Audiogram: normal in primary, unless co-exiting condition (indicated in hearing loss)
MRI: indicates central condition mimicking BPPV

Question 7

What is seen on supine lateral head turns

Answer 7

Diagnostic of lateral canal BPPV

The clinician places the patient in a supine position and, ideally, flexes the neck 30° from horizontal to bring the lateral canals into the vertical plane of gravity. However, it is sufficient and more usual to simply lay the patient flat on his or her back.
The head is then rotated to one side, left for a minute, and then rotated to the opposite side.

Horizontal nystagmus without a torsional (rotatory) component
Apogeotropic nystagmus (away from the ground) indicates cupulolithiasis
Geotropic (towards the ground) nystagmus indicates canalithiasis

The side with the stronger response corresponds to the affected canal in canalithiasis, and the weaker response corresponds to the affected canal in cupulolithiasis

Question 8

What is seen on Dix-Hallpike manoeuvre

Answer 8

The patient is seated and positioned on an examination table such that the patient’s shoulders will come to rest on the top edge of the table when supine, with the head and neck extending over the edge.
The patient’s head is turned 45° towards the ear being tested.
The head is supported, and then the patient is quickly lowered into the supine position with the head extending about 30° below the horizontal while remaining turned 45° towards the ear being tested.

The head is held in this position and the physician checks for nystagmus.
To complete the manoeuvre, the patient is returned to a seated position and the eyes are again observed for reversal nystagmus.

Positive - Vertigo with the appropriate position-provoked nystagmus response; the nystagmus and vertigo occur with 1 to 5 seconds of latency and last <30 seconds
Nystagmus is torsional (rotatory) in nature, reversible with sitting, and fatigable with repeat testing and unilateral

Left ear BPPV has a clockwise torsional nystagmus response
Right ear BPPV has an anti-clockwise response

Question 9

Management for Benign Paroxysmal Positional Vertigo

Answer 9

Epley manoeuvre
If symptoms do not settle after a week, repeat 1 week later

Brandt-Daroff exercises at home

Consider need for informing the DVLA

± betahistine (histamine analogue)