BPPV Flashcards
What is BPPV?
A peripheral vestibular disorder that manifests as sudden, short-lived episodes of vertigo elicited by specific head movements.
Describe the below tests:
- Epley manoeuvre
- Hallpike test
- Halmagyi test
- Romberg test
- Unterberger test
Dix-Hallpike test = diagnostic test for the most common type of BPPV (viz. affecting the posterior semicircular canal).
Epley manoeuvre = treatment for BPPV.
Halmagyi (HIT) and Unterberger (stepping) tests = for vestibular dysfunction in general.
Romberg test = for impaired proprioception.
What is the difference between a central and peripheral nystagmus in terms of diagnosis? Why might fixation make a nystagmus worse?
Peripheral - horizontal or vertical eye movements which can be evoked, positional (by turning the head), or spontaneous.
Central - usually vertical and is worsened by fixation of the gaze (Visual fixation is removed by blocking the information being sent to the brain by blinding the eye; the brain no longer has information to suppress the nystagmus so it gets worse.)
What 3 areas should you examine in acute vertigo?
- Eyes - gaze, VOR (vestibulo-ocular reflex tested with head impulse test, +ve in BPPV), hallpike, fundoscopy
- Ears - otoscopy
- Legs - gait
What are the characteristics of BPPV vertigo?
LATENCY, ADAPTABILITY, FATIGUABILITY.
- *Positional** - when lying back and turning over in bed (vertigo brough on by head turning?)
- *Brief** - seconds (but may come with prolonged malaise)
What are the most common vertigo diagnoses?
- Benign paroxysmal positional vertigo - 35%
- Vestibular neuritis - 15%
- Migrainous vertigo - 15%
- Stroke (cerebellar) - 5%
- Mixed (syncope, anxiety..) - 30%
- Meniere’s <1% - NOT COMMON !
What is the aetiology of BPPV?
Most cases result from the migration of free-floating endolymph canalith particles into the posterior (more commonly), horizontal, or anterior semicircular canals, rendering them sensitive to gravity.
Semicircular canals detect angular acceleration of the head and are involved with the VOR (enables visual fixation on a target while the head is moving)
Two pathophysiological mechanisms of BPPV:
- Canalithiasis - most common
- Cupulolithiasis - involved in lateral/horizontal BPPV
How common is BPPV?
BPPV is one of the most common causes of vertigo
Usually between 50-70yrs
Lifetime prevalence of 2.4%
What are the risk factors for BPPV?
- Hx of BPPV
- Old age
- Female
- Head trauma
- Viral infection (URTI)
- Hx of:
- Vestibular neuritis
- Labyrinthitis
- Migraines
- Inner ear surgery
- Meniere’s disease
What are the clinical features of BPPV?
- Brief duration - but >30 seconds.
- Sudden onset
- Intense vertigo
- Position specific
- Episodes of vertigo
- Nausea, imbalance, lightheadedness
Exclude:
No tinnitus, no hearing loss
No headaches, no visual symptoms
No motor abnormalities
What investigations would you do for BPPV?
Dix-Hallpike test - torsional nystagmus; right ear anti-clockwise, left ear clockwise nystagmus. Used for posterior and anterior canal BPPV.
Supine lateral head turn - may be needed to diagnose horizontal canal BPPV.
To exclude other conditions:
Audiograms - normal in BPPV but SN hearing loss in Menieres
Brain MRI - exclude MS, posterior fossa tumours or ischaemic processes
Describe the Dix-Hallpike test.
- Fatiguable nystagmus on performing the Dix-Hallpike test is diagnostic.
- The patient sits on the examination table, his or her head is turned 45° to one side, and then the patient is laid back into a supine position, with the head hanging back but supported by the examiner and the neck extended by about 30°. Eyes must be open.
- Dix-Hallpike is positive when the patient experiences vertigo and nystagmus in the head hanging position.
- Nystagmus usually has a latency of 2-5 seconds, a crescendo-decrescendo pattern of intensity, and is transient (typically lasting <30 seconds)
What is the management of BPPV in order of best to worst?
- Epley manoeuvre = specific treatment for BPPV and has an 80% cure rate when used properly
- Cawthorne-Cooksey exercises = vestibular rehabilitation
- Watch and wait = in most cases self-limiting
- Prochlorperazine = drugs are ineffective; prochlorperazine would in principle help with the symptoms but often has side-effects…
- Cyclizine = only for nausea, not dizziness.
How do you manage BPPV?
Conservative:
- Watchful waiting + reassurance - self resolves within 3 weeks-6months
- Epley manoeuvre/3-position particle repositioning (PRM) -
- Semont maneouvre - if PRM fails then use this
- Vestibular rehabilitation exercises e.g. Brandt-Daroff exercises; can give leaflets
Medical:
-
Vestibular suppressant medication – no effect on BPPV outcomes. Used PRN:
- benzodiazepines (lorazepam, diazepam)
- antihistamines (meclozine, dimenhydrinate promethazine)
Surgical (<1%):
- Singular neurectomy
- Posterior canal occlusion - best procedure; based on occluding posterior semicircular canal so endolymph cannot move and cause symptoms.
Don’t forget
- Ask about driving
- Inform employer / workplace
- Advise about risk of falls
What would your differentials for sudden onset vertigo be?
- Benign paroxysmal positional vertigo (BPPV) – where specific head movements cause vertigo
- Labyrinthitis – an inner ear infection caused by a cold or flu virus
- Vestibular neuronitis – inflammation of the vestibular nerve
- Ménière’s disease – a rare inner ear condition, which sometimes involves tinnitus or loss of hearing
Label these semicircular canals.
What is canalithiasis vs cupulolithiasis?
Canalithiasis = debris loose within fluid pathways of the inner ear
Cupulolithiasis = debris attached to the cupula of one of the canals (when the cupula is horizontal there is no nystagmus/dizziness)
This is stones in different parts of the inner ear.
What is shown?
Semont maneouvre - liberatory, used for the posterior semicircular canals. Easier to carry out than PRM or used if PRM has failed.
