Benign Paroxysmal Positional Vertigo Flashcards
What is benign paroxysmal positional vertigo (BPPV)?
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.
Briefly describe the pathophysiology of BPPV
Migration of free-floating endolymph canalith particles (thought to be displaced otoconia from the utricular otolithic membrane) into the posterior (more commonly), horizontal (less commonly), or anterior (rarely) semicircular canals, rendering them sensitive to gravity.
What are the risk factors for BPPV?
- Increasing age
- Female
- Head trauma
- Vestibular neuronitis
- Labryinthitis
- Migraines
- Inner ear surgery
- Meniere’s disease
What are the signs of BPPV?
- Normal neurological examination
- Normal otological examination
- Positive Dix-Hallpike manouvere or position supine lateral head turn
What are the symptoms of BPPV?
- Specific provoking positions
- Brief duration of vertigo
- Episodic vertigo
- Severe episodes of vertigo
- Sudden onset of vertigo
- Nausea, imbalance and vertigo
- Absence of associated neurological and otological symptoms
What investigations should be ordered for BPPV?
- Dix-Hallpike manouvere
- Supine lateral head turns
Why investigate using Dix-Hallpike manouvere? And what may this show?
- Used to diagnose posterior canal BPPV.
- 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.
Why investigate using supine lateral head turns? And what may this show?
- Used to diagnose lateral (horizontal) canal BPPV.
- Horizontal nystagmus without a torsional (rotatory) component; apogeotropic nystagmus (away from the ground) indicates cupulolithiasis, and geotropic (towards the ground) nystagmus indicates canalithiasis.
Briefly describe the treatment for BPPV
- Patient education and reassurance.
- 3-position particle repositioning manouvere (Epley manouvere).
When is surgery appropriate to treat BPPV?
The vast majority of BPPV cases will respond to the repositioning manoeuvres or resolve spontaneously. The surgical treatment of BPPV is reserved for unrelenting, incapacitating cases where repeated attempts with repositioning manoeuvres and vestibular rehabilitation exercises have failed.
What is the recommendation for BPPV and driving?
The vast majority of BPPV cases will respond to the repositioning manoeuvres or resolve spontaneously. The surgical treatment of BPPV is reserved for unrelenting, incapacitating cases where repeated attempts with repositioning manoeuvres and vestibular rehabilitation exercises have failed.
What complications are associated with BPPV?
- Peri- or post- repositioning manouvere related BPPV
- Peri- or post- repositioning manouvere related nausea, emesis, autonomic dysfunction or imbalance
- Falls
What differentials should be considered in BPPV?
- Meniere’s disease
- Vestibular neuronitis
- Labyrinthitis
How does BPPV and Meniere’s disease differ?
- Signs and symtpoms: associated hearing loss, tinnitus, and aural fullness that is often exacerbated during an episode of vertigo. Recurrent episodes of vertigo last for minutes to hours and are not provoked by positional changes.
- Investigations: audiogram will demonstrate a sensorineural hearing loss, usually unilateral and initially worse in the low frequencies.
How does BPPV and vestibular neuronitis differ?
- Signs and symptoms: often a single episode of persistent vertigo lasting for days. The vertigo can be exacerbated by any positional change, unlike the specific head movements that induce BPPV attacks. May be preceded by a non-specific viral infection.
- Investigations: little or no nystagmus or vertigo during Dix-Hallpike testing.
