Benign paroxysmal positional vertigo

Question 1

What is the most common cause of vertigo?

Answer 1

Benign paroxysmal positional vertigo

Question 2

Pathophysiology of Benign paroxysmal positional vertigo

Answer 2

Otoliths (calcium carbonate in the semi-circular canals) become detached from the macula (the receptor part in the utricle)

The posterior semi-circular canal is the most affected (85-95%)
Inferior SSC - 5-15%
anterior SSC - rarely affected

Usually the hair cells in the otoliths are stimulated by the flow of endolymph which moves when the head moves.
But because they are detached, they keep moving around and stimulating nerve impulses - giving the sensation of vertigo

Question 3

Causes of Benign paroxysmal positional vertigo

Answer 3

60% idiooathic

head injury, spontaneous degenerative of the labyrinth, post viral neuronitis, complication of stapes surgery

Question 4

epidemiology

Answer 4

common
onset 40-60
2women:1man

Question 5

history of Benign paroxysmal positional vertigo

Answer 5

episodes of vertigo provoked by head movements (rolling over in bed)
usually worse when head is tilted to one particular side
attacks resolve after 20-30seconds if head is kept still
brief latent period between movement and attacks (5-20s)
worse in morning
nausea common

Hearing and tinnitus are NOT affected

Question 6

test to confirm benign paroxysmal positional vertigo (of posterior canal)

Answer 6

Dix-Hallpike test

hold patients head, turn to left side, then lie them down quickly - on their left side. This should trigger nystagmus and vertigo symptoms for 30s (ish)
Repeat on the right side - should be worse on one side

Question 7

differential diagnoses for vertigo/nystagmus

Answer 7

Benign paroxysmal positional vertigo

Acute vestibular labyrinthitis.
Multiple sclerosis.
Ménière’s disease.
Cerebrovascular disease - transient ischaemic attack (TIA), stroke.
Posterior cranial fossa tumours - eg, acoustic neuroma.
Brainstem lesions.
Herpes zoster oticus (Ramsay Hunt syndrome).
Otosclerosis.
Vertebrobasilar insufficiency.
Cholesteatoma.

Question 8

treatment for Benign paroxysmal positional vertigo

Answer 8

Epley’s manoeuvre
This is the most widely used repositioning manoeuvre for BPPV. Its aim is to reposition otoliths back into the utricles from the posterior semicircular canals.

Sit the patient upright on the couch with their head turned 45° to the affected side (the side that tested positive using the Dix-Hallpike test).
Place your hands on either side of the patient’s head and guide the patient to lie down with the head dependent 30° over the edge of the couch (the same as in the Dix-Hallpike test). Wait 30-60seconds

Rotate their head 90° to the opposite side with the patient’s face upward with the head remaining dependent.
Roll the patient on to their side whilst holding their head in this position and then rotate the head so that it is facing downwards (tell the patient to look to the ground).
Sit the patient up sideways while maintaining head rotation.
Simultaneously rotate the head to a central position.

(There should be no nystagmus by this stage, if the procedure has been successful, as the otoliths should by now be repositioned.)