Benign Paroxysmal vertigo Flashcards
What is the definition of Benign Paroxysmal vertigo (BPPV)
Benign paroxysmal positional vertigo (BPPV) is a common cause of recurrent episodes of vertigo triggered by head movement. It is a peripheral cause of vertigo, meaning the problem is located in the inner ear rather than the brain. It is more common in older adults
Epidemiology of BPPV?
it is one of the most common causes of vertigo
also it is the number one vestibular disorder accounting for a 20-30% of referrals to vertigo clinics (2)
the incidence of benign positional vertigo has been estimatesd to be between 10.7 to 64 per 100,000 population per year
the life time prevalence is 2.4 (2)
most patients are older than 40 years (most commonly between the fifth and seventh decades of life) but all age groups can be affected.
women have double the incidence of men.
Aetiology of BPPPV
- The aetiology of most cases of BPPV is unknown (idiopathic).
Secondary causes of BPPV can be due to various disorders which damage the inner ear
- head trauma
- mastoid surgery
- vestibular neuritis
- labyrinthitis
- Meniere’s disease
incidence of BPPV has shown to be higher in patients with migraine. BPPV is also reported to occur with giant-cell arteritis, diabetes, and hyperuricaemia
Traumatic forms of BPPV show which characteristics?
- higher incidence of bilaterality
- several canals on the same side can be affected
- seen equally among women and men
- more difficult to treat
- recurrence of the disease occurs frequently
What is the presentation of BPPV?
A variety of head movements can trigger attacks of vertigo. A common trigger is turning over in bed. Symptoms settle after around 20 – 60 seconds, and patients are asymptomatic between attacks. Often episodes occur over several weeks and then resolve but can reoccur weeks or months later.
BPPV does not cause hearing loss or tinnitus.
Pathophysiology of BPPV
BPPV is caused by crystals of calcium carbonate called otoconia that become displaced into the semicircular canals. This occurs most often in the posterior semicircular canal. They may be displaced by a viral infection, head trauma, ageing or without a clear cause.
The crystals disrupt the normal flow of endolymph through the canals, confusing the vestibular system. Head movement creates the flow of endolymph in the canals, triggering episodes of vertigo.
What are the most common provocative movements of BPPV?
rolling over in bed
bending over
looking upward (3)
Which of the 3 semi-circular canals can be seen in this disease?
Involvement of all three semi circular canals can be seen in this disease with the posterior (60-90%) and horizontal (5-30%) canals being the most commonly affected ones (2,4). However the prevalence of horizontal canal BPPV is more than what was previously thought (4).
What is the Dix- Hallpike manoeuvre?
The Dix-Hallpike manoeuvre can be used to diagnose BPPV (Dix for Dx – diagnosis)
It involves moving the patient’s head in a way that moves endolymph through the semicircular canals and triggers vertigo in patients with BPPV. Check the patient can do the manoeuvre safely before performing it, for example, ensuring they have no neck pain or pathology.
How do you perform the Dix-Hallpike manoeuvre?
The patient sits upright on a flat examination couch with their head turned 45 degrees to one side (turned to the right to test the right ear and left to test the left ear)
Support the patient’s head to stay in the 45 degree position while rapidly lowering the patient backwards until their head is hanging off the end of the couch, extended 20-30 degrees
Hold the patient’s head still, turned 45 degrees to one side and extended 20-30 degrees below the level of the couch
Watch the eyes closely for 30-60 seconds, looking for nystagmus
Repeat the test with the head turned 45 degrees in the other direction
In patients with BPPV, what will the Dix-Hallpike manoeuvre trigger?
trigger rotational nystagmus and symptoms of vertigo. The eye will have rotational beats of nystagmus towards the affected ear (clockwise with left ear and anti-clockwise for right ear BPPV).
Diagnostic criteria for BPPV
A. At least five attacks fulfilling criteria B and C
B. Vertigo* occurring without warning, maximal at onset and resolving spontaneously after minutes to hours without loss of consciousness
C. At least one of the following five associated symptoms or signs:
- nystagmus
- ataxia
- vomiting
- pallor
- fearfulness
D. Normal neurological examination and audiometric and vestibular functions between attacks
E. Not attributed to another disorder **
- Young children with vertigo may not be able to describe vertiginous symptoms. Parental observation of episodic periods of unsteadiness may be interpreted as vertigo in young children.
** In particular, posterior fossa tumours, seizures and vestibular disorders have been excluded
What is the Epley manoeuvre?
The Epley manoeuvre can be used to treat BPPV. The idea is to move the crystals in the semicircular canal into a position that does not disrupt endolymph flow.
How does one perform the Epley manoeuvre?
Follow the steps of the Dix-Hallpike manoeuvre, having the patient go from an upright position with their head rotated 45 degrees (to the affected side) down to a lying position with their head extended off the end of the bed, still rotated 45 degrees
Rotate the patient’s head 90 degrees past the central position
Have the patient roll onto their side so their head rotates a further 90 degrees in the same direction
Have the patient sit up sideways with the legs off the side of the couch
Position the head in the central position with the neck flexed 45 degrees, with the chin towards the chest
At each stage, support the patient’s head in place for 30 seconds and wait for any nystagmus or dizziness to settle
What are Brandt-Daroff exercises?
Brandt-Daroff exercises can be performed by the patient at home to improve the symptoms of BPPV. These involve sitting on the end of a bed and lying sideways, from one side to the other, while rotating the head slightly to face the ceiling. The exercises are repeated several times a day until symptoms improve.
