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Year 3 > Benign paroxysmal positional vertigo (ENT) > Flashcards

Benign paroxysmal positional vertigo (ENT) Flashcards

1
Q

Define BPPV.

A

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

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2
Q

What are some causes of BPPV? (8)

A
  • idiopathic (primary BPPV - 50-70%)
  • head trauma
  • labyrinthitis
  • vestibular neuronitis
  • Meniere’s disease
  • migraines
  • ischaemic processes
  • iatrogenic
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3
Q

What are most cases of BPPV a result of?

A

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

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4
Q

What groups is BPPV more common in? (2)

A
  • F>M
  • incidence 50-70 years old
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5
Q

What are the clinical features of BPPV? (4)

A
  • 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
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6
Q

What is seen on examination of BPPV? (2)

A
  • absence of neurological/otological symptoms (hearing loss, tinnitus, aural fullness)
  • positive Dix-Hallpike manoeuvre or positive supine lateral head turn
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7
Q

When do we consider another diagnosis to BPPV? (3)

A
  • if vertigo lasts >1min
  • if associated hearing loss
  • if associated neurological symptoms
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8
Q

What is more likely than BPPV in an elderly patient that is dizzy on extending their neck?

A

Vertebrobasilar ischaemia (not BPPV)

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9
Q

What is vestibular neuronitis, how does it present, and how is it managed?

A
  • 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)
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10
Q

What is viral labyrinthitis and how does it present?

A
  • inner ear infection
  • similar to vestibular neuritis (vertigo hours/days, N&V, balance issues, horizontal nystagmus) but with hearing loss and tinnitus
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11
Q

What would acoustic neuroma present like? (4)

A
  • vertigo
  • hearing loss
  • tinnitus
  • absent corneal reflex
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12
Q

What are some risk factors for BPPV? (8)

A
  • increasing age
  • female sex
  • head trauma
  • vestibular neuronitis
  • labyrinthitis
  • migraines
  • Meniere’s
  • inner ear surgery
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13
Q

What are the first line investigations for BPPV? (2)

A
  • Dix-Hallpike manoeuvre
  • supine lateral head turns
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14
Q

What type of BPPV is the Dix-Hallpike manoeuvre used to diagnose?

A

Posterior canal BPPV

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15
Q

Describe the Dix-Hallpike manoeuvre for BPPV.

A
  • 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
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16
Q

What is a positive result for the Dix-Hallpike manoeuvre for BPPV?

A
  • 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
17
Q

When is the Dix-Hallpike manoeuvre contraindicated in BPPV?

A

Cervical spine injury/fusion; can be carried out carefully in patients with cardiovascular risks

18
Q

What type of BPPV is supine lateral head turns used to diagnose?

A

Lateral (horizontal) canal BPPV

19
Q

Describe supine lateral head turns for BPPV.

A
  • 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
20
Q

What is a positive result for supine lateral head turns for BPPV?

A
  • 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)
21
Q

What other investigations can be considered for BPPV, to rule out other causes? (2)

A
  • audiogram
  • brain MRI (exclude CNS conditions)
22
Q

What are some differential diagnoses for BPPV? (6)

A
  • 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
23
Q

What is the management plan for BPPV?

A
  • 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)
24
Q

What is the first line treatment for BPPV?

A

Epley manoeuvre AKA 3-position particle repositioning manoeuvre

25
Q

What are some complications of BPPV? (5)

A
  • 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
26
Q

Describe the prognosis of BPPV.

A
  • majority of cases resolve from repositioning manoeuvres or spontaneously
  • 1/2 with BPPV will have recurrence 3-5 years after diagnosis

Year 3 (148 decks)

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