Benign paroxysmal positional vertigo (ENT) Flashcards
Define BPPV.
Peripheral vestibular disorder that manifests as sudden, short-lived episodes of vertigo elicited by specific head movements
One of the most common causes of vertigo
What are some causes of BPPV? (8)
- idiopathic (primary BPPV - 50-70%)
- head trauma
- labyrinthitis
- vestibular neuronitis
- Meniere’s disease
- migraines
- ischaemic processes
- iatrogenic
What are most cases of BPPV a result of?
Migration of free-floating endolymph canalith particles (displaced otoconia from the utricular otolithic membrane) into the semicircular canals (posterior > horizontal > anterior), rendering them sensitive to gravity
What groups is BPPV more common in? (2)
- F>M
- incidence 50-70 years old
What are the clinical features of BPPV? (4)
- vertigo provoked by specific positions (looking up, bending down, turning head, rolling onto one side)
- brief duration of vertigo (<1min)
- sudden onset, severe, episodic vertigo
- nausea, imbalance and light-headedness
What is seen on examination of BPPV? (2)
- absence of neurological/otological symptoms (hearing loss, tinnitus, aural fullness)
- positive Dix-Hallpike manoeuvre or positive supine lateral head turn
When do we consider another diagnosis to BPPV? (3)
- if vertigo lasts >1min
- if associated hearing loss
- if associated neurological symptoms
What is more likely than BPPV in an elderly patient that is dizzy on extending their neck?
Vertebrobasilar ischaemia (not BPPV)
What is vestibular neuronitis, how does it present, and how is it managed?
- inflammation of the vestibular portion of vestibulocochlear nerve, associated with viral infection
- vertigo lasting hours-days
- nausea and vomiting
- balance problems
- horizontal nystagmus
- no hearing loss or tinnitus
- treatment: prochlorperazine in the acute phase (stopped after few days as it delays recovery)
What is viral labyrinthitis and how does it present?
- inner ear infection
- similar to vestibular neuritis (vertigo hours/days, N&V, balance issues, horizontal nystagmus) but with hearing loss and tinnitus
What would acoustic neuroma present like? (4)
- vertigo
- hearing loss
- tinnitus
- absent corneal reflex
What are some risk factors for BPPV? (8)
- increasing age
- female sex
- head trauma
- vestibular neuronitis
- labyrinthitis
- migraines
- Meniere’s
- inner ear surgery
What are the first line investigations for BPPV? (2)
- Dix-Hallpike manoeuvre
- supine lateral head turns
What type of BPPV is the Dix-Hallpike manoeuvre used to diagnose?
Posterior canal BPPV
Describe the Dix-Hallpike manoeuvre for BPPV.
- patient seated and positioned such that the patient’s shoulders will come to rest on the top edge of the table when supine, with head and neck extending off edge
- patient’s head turned 45 degrees towards ear being tested
- head is supported, patient is quickly lowered into supine position with head extending 30 degrees below horizontal while remaining turned 45 degrees
- the head is held in this position and physician tests for nystagmus
- to complete the manoeuvre, the patient is returned to a seated position
What is a positive result for the Dix-Hallpike manoeuvre for BPPV?
- delayed onset rotatory/torsional nystagmus unilaterally and vertigo
- nystagmus is rotational in nature, reversible with sitting and fatigable with repeat testing
- left ear BPPV has clockwise nystagmus response
- right ear BPPV has anti-clockwise nystagmus response
When is the Dix-Hallpike manoeuvre contraindicated in BPPV?
Cervical spine injury/fusion; can be carried out carefully in patients with cardiovascular risks
What type of BPPV is supine lateral head turns used to diagnose?
Lateral (horizontal) canal BPPV
Describe supine lateral head turns for BPPV.
- patient placed in supine position (and flexes neck 30 degrees from horizontal to bring lateral canals into vertical plane of gravity)
- head rotated to one side, left for 1-2 minutes, then rotated to opposite side
What is a positive result for supine lateral head turns for BPPV?
- similar to the Dix-Hallpike manoeuvre, a positive test is noted when the patient experiences vertigo with nystagmus
- horizontal nystagmus without rotatory/torsional component
- apogeotropic nystagmus (away from ground) indicates cupulolithiasis (weaker response is affected canal)
- geotropic nystagmus indicates canalithiasis (stronger response is affected canal)
What other investigations can be considered for BPPV, to rule out other causes? (2)
- audiogram
- brain MRI (exclude CNS conditions)
What are some differential diagnoses for BPPV? (6)
- Meniere’s disease - recurrent vertigo lasting hours, sensorineural hearing loss (unilateral + low frequency), aural fullness, tinnitus
- vestibular neuronitis - vertigo with movement in any plane (single episode exacerbated by positional change), lasts days, non-specific viral infection
- labyrinthitis - vertigo with movement in any plane (single episode), lasts days, sensorineural hearing loss +/- viral infection
- migraine - vertigo lasts longer
- perilymphatic fistula
- CNS disorder
What is the management plan for BPPV?
- patient education and reassurance (spontaneous remission in 1/3 at 3 weeks and most at 6 months from onset)
- 3-position particle repositioning manoeuvre (PRM) AKA Epley manoeuvre - set of specific sequential manoeuvres to move otoconia out of semi-circular canal and back into vestibule
- Semont repositioning manoeuvre (if Epley fails)
- CONSIDER at home vestibular rehabilitation exercises (Brant-Daroff exercises) 3-4 times/day until 2 consecutive days without symptoms
- CONSIDER vestibular suppressant medication (lorazepam/diazepam)
- if chronic and refractory –> surgery (very rare as most cases resolve spontaneously/repositioning manoeuvres)
What is the first line treatment for BPPV?
Epley manoeuvre AKA 3-position particle repositioning manoeuvre
What are some complications of BPPV? (5)
- peri/post-repositioning manoeuvre-related BPPV, nausea, emesis, autonomic dysfunction or imbalance
- falls in older patients
- accidents - road traffic/work/leisure
- hearing loss (surgery)
- conversion of BPPV to a lateral/anterior canal variant
Describe the prognosis of BPPV.
- majority of cases resolve from repositioning manoeuvres or spontaneously
- 1/2 with BPPV will have recurrence 3-5 years after diagnosis
