BPPV Flashcards
what population is BPPV seen in most frequently
70-79 y/o
– general trend of it being more prevalent later on into life
what canal is the most likely for BPPV to be in? why?
posterior
- gravity
explain the pathophys related to BPPV
otoconia detached from macula and fall into canal
explain the treatment for BPPV and its efficacy
1 treatment session typically with 2-3 treatments per session
- 85% remission
what are the goals of BPPV treatment
otoconia returning to the vestibule (more so to utricle)
remission of vertigo / symptoms
normalized postural control
self management
what is something to be weary of when educating patient on self-management
canal conversion can occur and then make BPPV/symptoms worse
explain the symptom of vertigo?
- subjective description
- onset
- duration
describe themselves or the room spinning
position induced, change of head position relative to gravity
brief duration (<1 min)
what % of patients will also report dysequilibrium
50
classic symptoms of BPPV
vertigo
disequilibrium
motion sensitivity
when examining patient, what is important to keep in mind regarding symptoms
latency period of otoconia movement in the SCC
- typically anywhere from 1 to 30 sec
what do we look for in a clinical exam of those with suspected BPPV
symptom onset
nystagmus and its direction
duration of nystagmus
– if it fatigues or not
what is the general duration of nystagmus in those with BPPV
<2 min
explain posterior canal and the muscles innervated by movement
- ipsilateral/contralateral
I - superior oblique
C - inferior rectus
explain anterior canal and the muscles innervated by movement
- ipsilateral/contralateral
I = superior rectus
C = inferior oblique
explain horizontal canal and the muscles innervated by movement
- ipsilateral/contralateral
I = medial rectus
C = lateral rectus
explain the nystagmus associated with posterior canal
— right vs left
R = up beat, right torsion
L = up beat, left torsion
explain the nystagmus associated with anterior canal
— right vs left
R = down beat, right torsion
L = down beat, left torsion
explain the nystagmus associated with horizontal canal
— right vs left
horizontal nystagmus
geotropic vs ageotropic
what is geotropic nystagmus? and ageotropic
nystagmus toward earth
nystagmus away from earth
canalithiasis and its effect
otoconia free-floating in semicircular canal that will fall to the lowest point
flow of endolymph and deflection of cupula
cupulolithiasis and its effect
otoconia adhering to cupula
increased density of cupula leads to gravity sensitivity
what is the test used for posterior and anterior canal assessment
Dix Hallpike test (DHP)
positioning of DHP
patient on exam table in long sit
head is turned 45°
patient is lowered to supine with neck extension of 30°
– nystamgus and symptom reproduction is assessed
what is a positive DHP test
if there is nystagmus and/or symptoms
–> testing whichever ear is closest to the ground, therefore will indicate canal issue in that ear
alternative assessment of anterior and posterior canal
side-lying test
side-lying test protocol
patient seated on edge of table
patient head is turned 45°
bring patient into sidelying position with head at 45° rotation
– assessment of nystagmus and/or symptom reproduction
explain the differentiator in canalithiasis and cupulolithiasis in nystagmus
canal = transient nystagmus (<1min)
cup - persistent nystagmus
preferred treatment method for severe posterior canalithiasis
canalith repositioning treatment
what is the preferred treatment method for posterior cupulolithiasis
liberatory (semont)
preferred treatment method for mild posterior canal BPPV
brandt-daroff
explain the difference between the Epley maneuver and canalith repositioning treatment
there is not one silly
explain CRT/Epley maneuver
patient head is rotated 45° toward involved side
patient is moved into DHP testing position with affected ear toward ground
patient is rotated 90° to the other side with back flat on table
patient is rolled onto contralateral shoulder
patient brought up into sitting position with head maintained in 45° rotation
what important to maintain during epley maneuver
neck extension of 20-30°
what is the duration of positioning in CRT
2x the duration of nystagmus noted in DHP testing
what is the speed at which one should do CRT? why?
slower is better than faster
–> symptoms are elicited with head movement, no need to make those worse
–> endolymph is viscous, want to allow for proper movement of otoconia
what should the patient be educated on post CRT?
patient may feel off for 2-3 days
–> can sleep on an extra pillow if they’d like
go back to normal life at your own discretion
protocol for liberatory maneuver
head rotated 45° contralaterally from affected side
move patient to ipsilateral side-lying of affected side (maintain for 1 min)
patient rapidly moved 180° to opposite side-lying
maintain original head position so that second sidelying has pt’s nose facing the table
–> maintain for 1 min
protocol for brandt-daroff maneuver
start in seated position
rotate head 45° to either side
quickly lie patient on opposite shoulder of head rotation
–> remain for 30 sec
repeat with head turned other way
what is the prescribed treatment associated with brandt-daroff maneuver
10-20x / 3x a day
–> until patient is without vertigo while completing for 2 consecutive days
how are the horizontal canals assessed
roll test
protocol for roll test
patient supine with 20° of cervical flexion
head turned 90° to a side
–> check for nystagmus and vertigo
returned to midline, repeated on other side
what type of nystagmus in a roll test would indicate canalithiasis?
which ear would be affected?
transient geotropic nystagmus
strongest nystagmus is ipsilateral
what type of nystagmus in a roll test would indicate cupulolithiasis?
which ear would be affected?
persistent ageotropic nystagmus
strongest nystagmus is contralateral
what treatment method is indicated for horizontal canalithiasis
CRM for horizontal
liberatory maneuver
what treatment method is indicated for horizontal cupulolithiasis
gufoni maneuver
CRM for horizontal canal BPPV protocol
head in 20° cervical flexion
place patient’s head in 90° rotation (affected ear down)
head rotated to midline with back of the head down
–> maintain for 15 sec or until symptoms fade
rotate patient’s head 90° to the opposite side (unaffected ear down)
–> maintain for 15 sec or until symptoms fade
roll patient into prone position
–> maintain until symptoms stop
what is important to remeber during CRM treatment of horizontal canal?
try to maintain 20° flexion during each transition, especially going from sidelying to prone
protocol for liberatory maneuver
patient in seated
pt brought to unaffected sidelying position
–> maintained for 2 min
pt’s head is turned 45° toward the table
–> maintained for 2 min
pt returned to seated
–> repeated to the other side
what is the protocol for gufoni method
just kinda came up with this, not specifically listed
patient in seated position
patient brought to side-lying
patient face rotated to toward mat
if someone has a history of positional vertigo, but DHP was negative, what can be indicated
horizontal canal BPPV
explain the recurrence rate of BPPV? what can increase this?
25-50%
- highest within the first year
will increase with head trauma / age
explain the treatment of BPPV in the 1st vs 2nd visit
1 - treat and educate
– self management via head elevation during sleep/ not to roll
2 - reassess and treat
- consider teaching pt to self-treat
explain why BPPV treatments may not work
they don’t have BPPV
user error / misread of tests
canal conversion
for treatment of BPPV in elderly populations, what are some special considerations?
neck/back range of motion and pain
speed of the treatment movements
cognition/understanding of treatment
