BPPV Flashcards
What is the Dizziness Handicap Inventory (DHI) used for?
It is used to provide a clinical diagnostic hypothesis for examination
There are five items predictive of BPPV on it (items 1,5,11,13,25)
What are the five items of the DHI that are predictive of BPPV?
Items 1,5,11,13,25
What is the MDC of the DHI?
17.18
What are the causes of BPPV?
Trauma
Infection
Idiopathic
Advanced age
What is secondary BPPV?
BPPV that occurs from a weakened vestibular system like a unilateral vestibular neuritis
Pts with a hx of what conditions may be a risk for BPPV?
Osteoporosis, CABG, uncontrolled HTN, and vitamin D deficiency
What is the most common cause of vertigo?
BPPV
What is BPPV (Benign Paroxysmal Positional Vertigo)?
A mechanical disorder caused by the otoconia being displaced from the macula of the utricle
T/f: BPPV is the easiest disorder to successfully ID and treat
True
T/f: in BPPV, calcium particles can be displaced into one or more of the 3 SCC
True
Order the SCC from most to least likely to get BPPV?
Posterior, horizontal, anterior
T/f: BPPV is usually on one side except in cases of trauma and systemic infection
True
When do symptoms occur and dissipate in BPPV?
Symptoms occur with position changes while the crystals are still moving
Symptoms stop once the crystals settle into place (usually less than 1 min)
T/f: the symptoms of BPPV are very random and hard to distinguish
False, they are happen very regularly and predictably
T/f: BPPV is very mechanical and reproducible
True
What is cupulolithiasis?
When the otoliths are attached to the cupula, increasing the deflection of the cupula and creating a sense of dizziness
How long do symptoms last with cupulolithiasis? Why?
As long as they are in the provoking position bc the otoconia are persistently pulling in the cupola to create the illusion of spinning
What is canalolithiasis?
When the otoliths are free floating in the endolymph of the canal, increasing deflection of the cupula
How do symptoms occur in canalolithiasis?
When put into the provoking position, the symptoms will have a crescendo, peak, then decrescendo within a minute
Is cupulolithiasis or canalolithiasis more common?
Canalolithiasis
Does cupulolithiasis or canalolithiasis have more intense nystagmus?
Canalolithiasis
Does cupulolithiasis or canalolithiasis have longer lasting symptoms in the provoking position?
Cupulolithiasis
Is cupulolithiasis or canalolithiasis easier to treat?
Canalolithiasis
How does hyper deflection of the cupula cause sensation of spinning?
Bc the brain sees this an increased firing in that canal which is asymmetrical to the other ear causing a profound sense of dizziness
What is Ewalds first law?
The axis of nystagmus parallels the anatomical axis of the SCC that generated it (each SCC produces a different nystagmus)
What is Flourens Law?
The nystagmus direction defines the canal
What nystagmus does L anterior SCC involvement produce? What muscles produce this?
Down beating left torsional nystagmus
Inferior oblique and opposite superior rectus
What nystagmus does R anterior SCC involvement produce? What muscles produce this?
Down beating R torsional nystagmus
Inferior oblique and opposite superior rectus
What nystagmus does L posterior SCC involvement produce? What muscles produce this?
Upbeating L torsional nystagmus
Superior oblique and CL inferior rectus
What nystagmus does R posterior SCC involvement produce? What muscles do this?
Upbeating R torsional nystagmus
Superior oblique and CL inferior oblique
What nystagmus does horizontal SCC involvement produce? What muscles do this?
Purely linear nystagmus
Ipsilateral medial rectus and CL lateral rectus
The SCCs work in pairs and in each pair, when one is_____ the other is ____
Excited, inhibited (or vice versa)
The horizontal SCC are paired together, so what are the vertical canal pairs?
RALP (R ant L post)
LARP (L ant R post)
T/: the assessments for BPPV recreate the patient’s issue
True
What is hemodynamic orthostatic dizziness?
5/more episodes of dizziness, unsteadiness, or vertigo triggered by standing up or during upright position that subsides when sitting or laying down
Hemodynamic orthostatic dizziness is accompanied by at least one of the following symptoms:
Generalized weakness/tiredness, difficulty thinking/ concentrating, blurred vision, tachycardia/palpitations
What differentiates hemodynamic orthostatic dizziness from BPPV if both involve dizziness with postural changes?
The postural changes that will help relieve symptoms of hemodynamic orthostatic dizziness (laying down, sitting) are typically the most provocative positions for pts with BPPV
T/f: BPPV follows a “hallmark presentation” for positional nystagmus in trigger, symptoms, and nystagmus
True
What is normal physiologic nystagmus?
Nystagmus that occurs turning one way or with far end range gaze
What are the two types of pathologic nystagmus?
Spontaneous nystagmus
Simple nystagmus
What are the pure directions of simple nystagmus?
Linear (horizontal)
Mixed vertical/torsional
Vertical
Torsional
T/f: the direction of the nystagmus tells us what canal is involved
True
What canal creates linear (horizontal) nystagmus?
Horizontal SCCs
What canal creates mixed vertical/torsional nystagmus?
Vertical SCCs
What creates vertical nystagmus?
BS dysfunction
What creates torsional nystagmus?
Central processes
Nystagmus is named for the ____ phase
Fast
T/f: any unilateral loss of activity will cause nystagmus
True
What characteristics of nystagmus drive the determination of laterally?
Situation
Direction
Intensity
Duration
Is cupulolithiasis or canalolithiasis characterized by latent onset nystagmus of short duration with a clear crescendo/descrescendo?
Canalolithiasis
Is cupulolithiasis or canalolithiasis characterized by very latent onset nystagmus of long duration with no clear crescendo/descrescendo?
Cupulolithiasis
If you ask a patient to look in the direction of the fast phase of nystagmus, will it increase or decrease?
Increase
If you ask a patient to look in the direction of the slow phase of nystagmus, will it increase or decrease?
Decrease
Does the intensity of nystagmus increase with repetition of maneuvers in canalolithiasis?
No, it decreases
Does the intensity of nystagmus increase with repetition of maneuvers in cupulolithiasis?
No, it stays the same
T/f: both cupulolithiasis and canalolithiasis follow Alexander’s law, Ewalds law, and flourens law
True
What are CRMs?
Canalith repositioning maneuvers
Before doing any maneuvers for BPPV, what should we screen?
CLEAR THE NECK
How can we screen the neck before BPPV maneuvers? If the patients can hold the positions, what does it mean?
With the pt in sitting, place the head in 45 deg rotation on each side
If the position can be maintained for 30sec without pain or discomfort, then at least the SL test can be done
OR
place the patient’s head in 45 deg rotation with neck extension of each side
If this position can be maintained for 30sec without pain or discomfort then the Dix Hallpike maneuver can be performed as usual
What is VBI (vertebribasilar insuffiency)?
Vascular insufficiency caused by occlusion from head extension with symptoms of increasing dizziness, increasing visual abnormalities/nystagmus, or change/decrease in altertness
Increased symptoms in the Dix Hallpike testing can be caused by what two things?
BPPV
VBI
How can we assess for VBI before doing the DHT?
Clear the neck
Instruct the pt to bend forward at the waist with their elbows placed on their knees (trying to beget max cervical extension) and hold for >10sec
Then extend with rotation to each side for >10 sec
What cautions need to be considered before DHT?
Back and neck pain
Cardiopulmonary dysfunction
T/f: someone with severe cardiac/respiratory problems will be unable to tolerate such a procedure as DHT
True
What is the loaded DHT?
Loading the otoconia closer to the cupula by starting with neck flexion to get a bigger outcome
How can we hypothesize the involved side before the DHT?
Using the subjective report
How do we perform the Dix Hallpike maneuver?
Begin in long sitting with about a pillows length behind them and put the canal in the plane of gravity
Rotate the head towards the involved side 45 deg
Bring the pt quickly/safely back to the DHT position of 45 deg rot and 30 deg ext in supine
Which side should we test for when testing first BPPV?
The presumed negative/uninvolved side
How long should we stay in the end position of DHT?
One minute
How do we treat posterior canal BPPV?
With one basic CRM-the Epley maneuver
Should we wait to do the Epley maneuver after the DHT?
No, we should do it right from the DHT
How do we perform the Epley maneuver?
Begin in long sitting and rotate the head towards the involved side 45 deg Bring
Bring the pt quickly/safely back to the DHT position
Bring the head into 45 deg rot and 30sec ext to the other side without lifting the head
Ask the ot to bend one knee and reach for the edge of the table and roll into side lying with the neck still flexed (like smelling their armpit)
SLOWLY sit up maintain the flexed and rotated head position and repeat as needed
How long should the pt remain seated after the DHT?
10 minutes
How long should we maintain each position of the DHT?
Until the nystagmus stops plus 10-30 sec to ensure the otoconia have gathered together
What predicts the success of treatment with the Epley maneuver?
If you see nystagmus and it stays in the same direction it is a positive predictor
If you see a reversal in direction of nystagmus it is a poor predictor
What is the order of assessment for posterior BPPV?
DHT—>Epley—>DHT
What is the treatment of posterior cupulolithiasis?
The Semont maneuver
How do we perform the Semont maneuver?
To start sit on the edge of the exam table
Turn the head so it is 45 deg looking away from the affected side
Quickly lower the pat to the side that causes the worst vertigo, swinging the leg up onto the table (should be <1.5 sec)
When the head is in the table, the pat is looking up and hold this position for 30sec
Keep the head turned the same direction
Then quickly (<1.5 sec) move to the other side of the table looking toward the floor and hold this position for 30 sec
Repeat as needed and return to sitting position
After doing the Semont, what should we do?
DHT—>Epley—>DHT
Why do we do the Epley after the Semont?
Bc the Semont converts cupulolithiasis into canalolithiasis so we have to treat canalolithiasis after to get rid of symptoms
T/f: the horizontal canals can be stimulated in any position, making horizontal canals BPPV very functionally limiting
True
What is the most common atypical variant of BPPV?
Horizontal (lateral) canal BPPV
It is suggested that most cases of horizontal BPPV are a consequence of what?
Poor technique in the Epley maneuver or home maneuvers
What is ampullopetal flow?
Flow towards the ampulla that is excitatory in the horizontal SCC
What is ampullofugal flow?
Flow away from the ampulla that is inhibitory in the horizontal SCC
What will nystagmus for the horizontal SCC look like?
Horizontal nystagmus without torsion
T/f: the nystagmus with horizontal canal BPPV will occur with head movt in either direction
True
What are the 3 exam choices we have to evaluate horizontal canal BPPV?
Supine roll test
Sitting BLT-Bow and Lean test
Sit to supine test
How do we perform the supine roll test?
The out starts in supine with the horizontal canals against gravity
Quickly turn the head 90 deg in one direction and observe intensity of the nystagmus
Return the head to midline quickly turn the head 90 deg in the other direction and observe intensity of the nystagmus
How can we tell which type of horizontal BPPV is present?
By seeing whether the nystagmus beats up toward the ceiling or down towards the floor
What is geotropic nystagmus?
Horizontal nystagmus that beats toward the GROUND no matter which side you test
Does geotropic nystagmus indicate canalolithiasis or cupulolithiasis?
Canalolithiasis
What is ageotropic (apogeotropic) nystagmus?
Horizontal nystagmus that beats toward the CEILING no matter which side is tested
Does ageotropic nystagmus indicate canalolithiasis or cupulolithiasis?
Cupulolithiasis
With geotropic nystagmus, how can we tell the laterality of the nystagmus?
the involved ear is always in the side of the stronger nystagmus
With ageotropic nystagmus, how can we tell the laterality of the nystagmus?
The involved ear is always the side of the weaker nystagmus
What kind of BPPV is present with ageotropic nystagmus with stronger nystagmus on the L side?
R cupulolithiasis
What kind of BPPV is present with ageotropic nystagmus with stronger nystagmus on the R side?
L cupulolithiasis
What kind of BPPV is present with geotropic nystagmus with stronger nystagmus on the L side?
L canalolithiasis
What kind of BPPV is present with geotropic nystagmus with stronger nystagmus on the R side?
R canalolithiasis
What test can we do following the supine roll test if we arent confident in the side of involvement?
The BLT (bow and lean test)
When testing the horizontal canals with the bow test, what result confirms geotropic nystagmus?
The nystagmus beats towards the involved side
When testing the horizontal canals with the bow test, what result confirms ageotropic nystagmus?
Nystagmus beating away from the involved side
When testing the horizontal canals with the lean test, what result confirms geotropic nystagmus?
Nystagmus beats away from the involved side
When testing the horizontal canals with the lean test, what result confirms ageotropic nystagmus?
Nystagmus beats towards the involved side
How do we perform the sit to supine alternative test for horizontal canal BPPV?
Quickly take the pt back from long sitting straight back to supine position (neutral to 30 deg flex)
What horizontal canal BPPV test that uses the same mechanisms as the lean test but with more provactive stimulus
The sit to supine test
If the nystagmus beats towards the involved side with the sit to supine test, does this indicate geotropic or ageotropic nystagmus?
Ageotropic nystagmus
If the nystagmus beats away from the involved side with the sit to supine test, does this indicate geotropic or ageotropic nystagmus?
Geotropic nystagmus
What is the direction of spontaneous nystagmus with geotropic nystagmus?
Away from the side of involvement
What is the direction of spontaneous nystagmus in ageotropic nystagmus?
Towards the side of involvement
What are the treatment maneuvers for horizontal canal BPPV?
BBQ roll
Gufoni or Applani maneuver
Zuma maneuver (ageotropic)
Prolonged positioning
How do we perform the Balon 360 (BBQ) maneuver?
Place the pt in SL with the involved ear down or just face the head down towards the floor
Roll to supine (or just turn head up)
Continue to roll to the other side with involved ear up now
Continue to roll in the same direction to prone keeping the head tucked
Continue to roll in the same direction to SL and proceed to sitting or sit back in child’s pose and come to knees
Stay in each position until nystagmus stops plus 10 sec
How do we perform the Gufoni or Appiani maneuver for geotropic nystagmus?
The pt is quickly brought down from sitting to the SL position on the unaffected ear
After one minute, the head is quickly turned 45 deg downward so that the nose is directed downward
After 2 minutes, the pt is returned to sitting
What are the indications for the forced prolonged positioning technique?
Geotropic H SCC canalolithiasis resistant to treatment
What are the main two maneuvers used to treat horizontal canal BPPV?
BBQ roll and Gufoni maneuver
How do we decide whether to use the Gufoni or BBQ roll for H SCC?
Pt and PT preference
What is the procedure for the forced prolonged positioning?
Lie on the affected ear for 60sec
Roll to the unaffected ear and maintain this position overnight for at least 12 hours
If the pt gets out of bed, repeat the process
Is forced prolonged positioning done in the clinic or at home?
At home
How do we perform the Gufoni maneuver for ageotropic nystagmus?
Pt is quickly brought down to the SL position on the affected ear
After one minute in this position, the head of the pt is quickly turned 45 deg upward so that the nose is directed upward
After 2 minutes in this position, the pt is returned to sitting upright
Do the Gufoni maneuver for geotropic nystagmus
Why may we do the geotropic Gufoni after the ageotropic Gufoni?
Bc the ageotropic Gufoni converts the ageotropic cupulolithiasis BPPV into geotropic canalolithiasis BPPV
What are the indications for the Zuma maneuver?
Ageotropic HSCC BPPV
What is the procedure for the Zuma maneuver for ageotropic HSCC BPPV?
Lie the pt down on the affected side from sitting for 3 minutes
Rotate the head 90 to the ceiling and hold this position for 3 minutes
Roll to supine with the head rotated 90 deg away from the affected side and hold this position for 3 minutes
Return to sitting
How long should we try these maneuvers before we try a different one?
2-3x
How long should pts remain seating after these maneuvers?
10 minutes
T/f: there are special precautions pts should follow after BPPV maneuvers
False, there are not many anymore
T/f: the sooner we reintegrate pts into movement after BPPV maneuvers, the better their outcomes
True
What are the pt complaints with anterior canal BPPV?
Vertigo in pitch, often when bending over, emptying the dishwasher, weeding, etc
In the DHT position, what is the direction of nystagmus with anterior canal BPPV?
Primarily down beating
What are the 2 testing procedures for anterior canal BPPV?
DHT (standard 30 deg or deep 60 deg)
BL DHT
How do we perform the DHT for the anterior SCC?
Begin in long sitting and position the canal in the plane of gravity
Rotate the head from the presumed involved side 45 deg (essentially DHT toward good ear)
Bring the pt quickly/safely back to the DHT testing position of 45 deg rot/30-60 deg ext
How do we perform the BL DHT?
Pt should be brought back into supine with cervical spine 60 deg of ext without cervical rotation
When should we perform the BL DHT?
When the nystagmus isn’t clearly seen in the deep DHT and a side isn’t identified with anterior canal BPPV
What are the 3 basic CRMs for anterior canalolithiasis?
Supine 60 deg head hang
Yacovino 30 deg modification
Opposite side Epley maneuver (less desired)
If the offending side isn’t known in anterior canal BPPV canalolithiasis, what CRMs can we do?
Supine 60 deg head hang
Yacovino 30 deg modification
If the offending side is known in anterior canal BPPV canalolithiasis, what CRM can be used?
Opposite side Epley maneuver
How do we perform the supine head hang for treatment of anterior canalolithiasis?
Bring the pt straight back into supine with 60deg of head/neck ext with the head hanging over the edge of the table
Hold the position for 2 minutes to provide adequate time for the debris to settle in the anterior canal
Then the pt is returned to upright
The maneuver is repeated three times
How do we perform the Yacovino 30 deg modification of the supine head hang for anterior canalolithiasis?
Bring the pt straight back into supine with only 30 deg neck ext and hold for two minutes before returning to upright
How do we perform the opposite Epley maneuver for anterior canalolithiasis?
Begin in long sitting and rotate the head away form the involved side 45 deg
Bring the pt quickly back into a deep DHT position of 30-60 deg ext
Rotate head 45 deg and 30-60 deg ext the other way
Continue rolling to SL with the nose pointing down (flexed head position)
Slowly sit up maintaining the head position flexed and rotated
Maintain each position until the nystagmus stops plus 10 sec
How do we perform the “Semont maneuver” for the anterior SCC?
To start, sit on the edge of the exam table
Turn the head so it is 45 deg looking toward the side that causes the worst vertigo
Quickly lower the pt to the side that causes the worst vertigo with the pts nose to the table and hold the position for 30 sec
Keep the head turned the same direction
Then quickly move to the other side of the table without stopping in the upright position
When the head is on the table, the pt is looking up at the ceiling and hold this position for 30 sec
Repeat as necessary
What are the motion complaints with motion sensitivity?
Provoked dizziness during routine movt associated with daily living
What other condition other than BPPV can have positional symptoms?
Motion sensitivity
What pts often present with motion sensitivity?
Post concussion
Post head injury
Post whiplash
