L16: Benign paroxysmal positional vertigo (BPPV) assessment and treatment Flashcards
What does BPPV stands for?
Benign paroxysmal positional vertigo
What is BPPV triggered by?
Movement
____ is the single most common cause of dizziness in adults
BPPV
BPPV accounts for 20% of all presentations with ______
dizziness
BPPV accounts for 30% of all dizziness in ______ patients (>65yrs)
older
BPPV accounts for 80% of all dizziness in older patients (>_____yrs)
80
BPPV is a ____ problem.
Mechanical
How does BPPV occur?
Hardened otoconia dislodge from the utricle and “float” into the semi‐circular canals
- Canal is a one way system
Which canals does BPPV occur in most?
Mostly in posterior canal or horizontal canal (if side sleeper)
What are otoconia?
calcium carbonate crystals
Dislodgement of otoconia normally occurs as a result of damage to the _____/_____.
utricle / saccule
What are 5 possible mechanisms of how BPPV occur?
Anything that damages the inner ear
- Recent head injury (18%) – most common cause in people under 50
- Vestibular neuritis – 15%
- Other disorders of the ear
- Degeneration with age
- No specific cause
_____ increases the risk of BPPV by 15%.
Vestibular neuronitis
What is canalithiasis?
otoconia is freely mobile in the canal
Act like pebbles of a stream
- Slow down the fluid on one side
- As long as stop moving = will stop being affected
What is the symptom of canalithiasis?
Dizziness typically lasts less than a minute
What is cupulolithiasis?
otoconia adhere to the cupula
- Gravity will stick the otoconia in cupula
- Permanently deflect the cupula (in that position)
What is the symptom of cupulolithiasis?
Dizziness typically lasts more than a minute but may eventually fatigue
What are the 2 types of BPPV?
- Canalithiasis
- Cupulolithiasis
What are the 3 semi-circular canals?
- Posterior SCC = extension / rotation
- Anterior SCC = flexion / rotation
- Horizontal SCC = rotation / rolling
What head position is the posterior semi-circular canal stimulated by?
extension / rotation
- When they look up = dizzy
What head position is the anterior semi-circular canal stimulated by?
flexion / rotation
- When they look forward= dizzy
What head position is the horizontal semi-circular canal stimulated by?
rotation / rolling
The _____ SCC is by far the most commonly affected canal by BPPV.
posterior
What are 5 typical BPPV symptoms
- brief episodes of vertigo – typically lasting < 1 min
- imbalance
- motion sensitivity
- nausea
- occasionally lightheadedness (Mismatch and something moving)
BPPV is almost always brought on by a change of _____ position with respect to gravity
head
Head on body or body on head
What are 5 positions that may trigger BPPV symptoms?
- lying down in bed
- getting up in bed
- rolling over
- bending over
- looking up (ie. tipping head back)
What are 8 neurological signs that should not be typical BPPV symptoms (red flags)?
- weakness
- sensory changes
- dysarthria (Slowness of speech)
- dysphagia (Difficulty swallowing)
- decreased co‐ordination / ataxia (In limbs (eg. dropping))
- bladder / bowel problems
- diplopia (Double vision (either up centre or other quadrants))
- dysmetria (Clumsiness of limb coordination)
What are 3 indicators for BPPV?
- true vertigo - spinning (Eg. roll to the right –> likely to be the right side)
- brief episodes
- positional
- classic provoking positions can indicate affected side … but not always
What are 6 history symptoms for BPPV in the patient interview?
- Brief episode of spinning when rolling over in bed or sitting up out of bed
- Lasts for no more than 20 seconds
- No changes to hearing
- No tinnitus
- Able to walk around normally occasionally feels off balance
- No reported neurological signs
What are 2 previous medical history symptoms for BPPV in the patient interview?
- High blood pressure
- diabetes
What are the 3 different manoeuvres that can be used to assess for and diagnose BPPV?
- Dix‐Hallpike Test (PSCC and ASCC)
- Side‐Lying Test (PSCC and ASCC)
- Roll Test (HSCC)
What are 2 things that treatment is dictated by?
- proper identification of the involved canal (Side that is affected and which canal)
- determination of the type of BPPV:
- cupulolithiasis or canalithiasis
To diagnose BPPV of Posterior and Anterior canals during positional testing, what are 2 things you need to find out?
- Direction of the nystagmus will tell you which canal is involved
- Duration of symptoms will tell you the type of BPPV
To diagnose BPPV of Horizontal canals during positional testing, how is it different to posterior/anterior testing?
Are a little different – more on this soon!
What does the Dix-Hallpike Test assessment?
Tests posterior and anterior canal pairs
What are 3 steps in the Dix-Hallpike test?
- Patient sits with head turned 45°to one side
- Patient is then moved quickly backward so that the head is extended over the end of the table, approx. 30° below horizontal
- Performed to both right and left sides
What does a positive test for canalithiasis show in the Dix-Hallpike test?
Latency of 2‐10 sec after the head is moved into the position and gradual reduction of vertigo and nystagmus, duration
< 60sec = canalithiasis
What does a positive test for cupulolithiasis show in the Dix-Hallpike test?
Immediate onset of nystagmus , Vertigo after the head is moved into the position , sustained duration
> 60 secs (From lying down to symptoms subsiding)
What are 3 findings in the Dix-Hallpike test?
- Characteristic torsional nystagmus (Based on the superior part of eyes –> Why does it do opposite torsion? Pushing the fluid away)
- Reversal of nystagmus with vertigo on sitting up
- Fatigued response with repeated positioning
What does the Side-lying Test assessment?
both anterior and posterior SCC
When is the Side-lying Test used?
those who are anxious or do not tolerate cervical extension
What are 5 steps in the Side-lying test?
- Patient sits on the side of the bed with the head rotated 45° to one side
- Move down on their side opposite to the direction the head is turned
- Observe for direction of nystagmus and onset of vertigo
- Move back to sitting with the head still turned 45° and symptoms are checked
- Repeat to the other side
Diagnosis of BPPV canal and type with same symptom and nystagmus pattern as _______.
Dix‐Hallpike
What are 4 symptoms of canalithiasis?
- Delay in onset of symptoms
- Presence of nystagmus
- Duration of symptoms and nystagmus usually less than a minute (delayed onset lasting for <60)
- Most common type
What are 4 symptoms of cupulolithiasis?
- Immediate onset of symptoms
- Presence of nystagmus
- Symptoms persist for as long as head is in the provoking position (more than a minute) (sudden onset lasting >60secs)
- Relatively uncommon
What is the order from most common to least common (in term of canalithiasis/cupulolithiasis and anterior/horizontal/posterior)?
- Posterior canal
- Horizonal canal
- Posterior cupula
- Horizontal cupula
- Anterior canal
- Anterior cupula (sometimes central lesion looks like this) –> Very rare
What does nystagmus during testing in the posterior canal for the right and left?
RIGHT: R Torsional & Upbeating
LEFT: L Torsional & Upbeating
What does nystagmus during testing in the anterior canal for the right and left?
RIGHT: R Torsion & Downbeating
LEFT: L torsion & Downbeating
What does a R torsion mean?
R side affected
Make sure to don’t let them fixate. Why?
Won’t see nystagmus as much and but will still have symptoms
What test should be done on a Left PSCC canalithiasis BPPV?
Left Dix‐Hallpike test (delayed nystagmus gone within 60 secs)
What will you see in a Left PSCC canalithiasis BPPV after the Left Dix-Hallpike test?
Left torsional and Upbeating nystagmus
What test should be done on a Left ASCC canalithiasis BPPV?
Left Dix‐Hallpike test
What will you see in a Left ASCC canalithiasis BPPV after the Left Dix-Hallpike test?
Left torsional and Downbeating nystagmus
- Eyes starts slow –> crescendo —> gone within 60 secs
- Can be similar to central lesions (but it is slower and doesn’t crescendo)
What does the Roll test assess?
Diagnostic test for Horizontal SCC
What are 4 steps of the roll test for horizontal SCC?
- Patient lies supine with head flexed to 30° (Yaw)
- Into alignment of horizontal canal
- The head is quickly rolled to one side – aim 90° Can add body/log roll (to make sure 90 degrees) – watch for nystagmus and reports of vertigo
- The head is then slowly returned to the midline
- Repeated to the other side
If there is a horizontal canal BPPV, what do you see in the roll test?
vertigo and nystagmus will occur on both sides
The ______ of the nystagmus is dependent on whether it is canalathiasis or cupulothiasis
direction
What is the direction of the nystagmus for a Horizontal Canalathiasis BPPV?
nystagmus may fatigue and is geotrophic
What is the direction of the nystagmus for a Horizontal cupulolithiasis BPPV?
nystagmus persists and is apogeotrophic < 2 minutes
What is geotrophic?
“towards earth” – ie. Left roll test = left beating nystagmus
Left head on bed (towards ground)
What is the apogeotrophic?
“away from earth” – ie. Left roll test – right beating nystagmus
Cupulothiasis or a short arm canalthiasis
What would would see in a left roll?
left beating nystagmus (geotrophic)
What would you see in a right roll?
right beating nystagmus (geotrophic)
If there is Geotrophic nystagmus during right and left roll test, what does that mean?
canalithiasis
What must you do after you find out whether its a canalithiasis and cupulolithiasis?
Rate symptoms /5 or /10 each side to diagnose affected side
The more symptomatic side = has the crystals in it
- Horizontal is the only one (not A or P) that can’t tell what side because there is no torsional
What is right horizontal cupulolithiasis and canalithiasis like in terms of nystagmus?
Lt (apogeotrophic)
Rt (geotropic)
What is left horizontal cupulolithiasis and canalithiasis like in terms of nystagmus?
Rt (apogeotrophic)
Lt (geotropic)
In HSCC: up – cup – least?
apogeotrophic; cupulo; treat least symptomatic side?
Crystals are stuck to the least symptomatic side for cupulolithiasis for horizontal canal. Why?
- R = 2/10 –> pulling into the inhibitory system
- L = 5/10 –> pulling into excitatory R is the affected cupulolithiasis
Where are the crystals in the canalithiasis?
Crystals are on more symptomatic side.
What are 2 features of the Short arm Horizontal canal BPPV?
- Crystals sit at the very front of the HSC in the short arm.
- Can present differently from ‘usual HSC’ canaliasthiasis
What will be seen in the Short arm Horizontal canal BPPV in the right roll test?
apogeotrophic nystagmus < 2 minutes
What will be seen in the Short arm Horizontal canal BPPV in the left roll test?
apogeotrophic nystagmus < 2 minutes
But will fatigue so wait 2 mins (eg. true —> can last 5 mins)
What does the Horizontal Cupulolithiasis Canalithiasis Short arm for right nystagmus?
Lt (apogeotrophic)
Rt (geotropic)
Lt (apogeotrophic)
What does the Horizontal Cupulolithiasis Canalithiasis Short arm for left nystagmus?
Rt (apogeotrophic)
Lt (geotropic)
Rt (apogeotrophic)
What happens when you are unsure of the side of the crystal for the horizontal SC?
Bow and Lean
What is the bow and lean ?
Unsure of side of crystals for Horizontal SC
What are 2 steps of the bow and lean?
- Have patient sitting bow forward till nose is pointing to floor – observe direction of nystagmus
- Have patient then lean backward till nose is pointing too the ceiling – observer direction of nystagmus
What will happen to the canaliasthiasis in the bow?
will beat toward the side
What will happen to the cupulolithiasis and short arm in the bow?
will beat away from the side
What will happen to the canaliasthiasis in the lean?
will beat away from the side
What will happen to the cupulolithiasis and arm in the lean?
will beat toward the side
What happens in the bow and lean?
If the intensity in the roll test was the same (same symptoms on both sides)
- Confirmatory
What are 3 treatment options for BPPV?
- Canalith Repositioning Manoeuvres (CRM)
- Canal Liberatory Manoeuvres
- Brandt-Daroff Exercises
What is the purpose of treatment for BPPV?
Taking the crystals out
How long must CRM be held for?
Each position is held for 30sec‐ 2min (think double the test time)
- as a rule, should hold each position for double the duration of the nystagmus and vertigo noted during the DHT
What is the speed of the movement for CRM?
- Position of head with respect to gravity is more important than speed throughout the manoeuvre (for canalithiasis)
- slower speed will minimize symptoms
What are 3 contraindications for CRM?
- Severe carotid stenosis
- Unstable heart disease
- Severe cervical dysfunction (advanced rheumatoid arthritis, spondylosis)
What is the speed of the movements for liberatory manoeuvres?
Must be fast
How long must the liberatory manoeuvres be held for?
Each position is held for 2min to optimise flush.
- as a rule, should hold each position for double the duration of the nystagmus and vertigo noted during the DHT
What are 3 contraindications for liberatory manoeuvres?
- Severe carotid stenosis
- Unstable heart disease
- Severe cervical dysfunction (advanced rheumatoid arthritis, spondylosis)
What are the 2 manouvres for posterior and anterior canal as canalith re-positioning manoeuvires (CRM)?
- Modified Epley manoeuvre – canalithiasis
- 70 ‐ 90% response (1‐3 sessions)
- Is the same manoeuvre for both anterior and posterior canal canalathiasis
- Patient may experience vertigo throughout the treatment so you will need to reassure them
- Semont Liberatory manoeuvre – (also for cupulolithiasis)
- 50 ‐ 95% response (1‐5 sessions)
What are 3 characteristics of the Modified Epley manoeuvre?
canalithiasis
- 70 ‐ 90% response (1‐3 sessions
- Is the same manoeuvre for both anterior and posterior canal canalathiasis
- Patient may experience vertigo throughout the treatment so you will need to reassure them
What is a characteristic of the Modified Epley manoeuvre?
(also for cupulolithiasis)
- 50 ‐ 95% response (1‐5 sessions)
What are 4 steps of the Posterior canal cupulolithiasis (Semont- Liberatory Manoeuvre)?
- Patient is moved quickly into provoking position kept there for 2 min (ie. if left side is affected then down into left side‐lying)
- Patient rapidly moved up through sitting and down into the opposite side‐lying position with the therapist maintaining the alignment of the neck and head ie. The face is angled down toward the bed. Slam dunk
- Patient remains in this position for 2 min
- The patient is then returned slowly to sitting
What is the treatment for the AC Canaliasthiasis?
Treatment is the same as for posterior SCC for canaliasthiasis
What is the treatment for the AC Cupuloliasthiasis? List 3 characteristics.
Modified Liberatory Manoeuvre
- Difficulty = which side to treat as torsion difficult to see in anterior canal stimulation
- Base it on the direction of the nystagmus – not on the dependant ear
- Far less common (less than 5%) so ensure isn’t central
Post canal BPPV can convert to horizontal canal BPPV after the _____
CRM
What are 3 treatment options HSCC canalithiasis?
- BBQ roll
- Forced Prolonged Positioning
- Modified Brandt Daroff
What is the treatment option HSCC cupulolithiasis?
Casani manoeuvre (Semont manoeuvre modified by Casani)
What is the treatment option for HSCC short arm?
apogeotrophic variant – ‘New’ Gufoni or BBQ roll with extra rotation.
Bump and dunk (_____canals) Slam dunk (____ and ____ canals)
horizontal; anterior; posterior
What are 2 original instructions for post manoeuvre (Epley)?
- Patient put in soft collar and asked to remain upright for 48hrs
- Avoid lying on their affected side for 7 days
What are 3 current consensus for post manoeuvre (Epley)?
- Immediately post‐maneuver – patient should sit upright for 20‐ 30 minutes prior to leaving clinic
- Be particularly careful with elderly, when first get up to walk (Balance problems, damage to inner ear)
- Sleep with extra pillows for 1night and avoid provoking positions for 24 hours.
** it is debated amongst experts whether these instructions are necessary
What are the 4 characteristics about the number of treatments required?
- The CRM can be repeated multiple times in a session (3‐4 times if patient tolerating)
- Liberatory maneuver usually 1‐2 can also be followed up with CRM
- If you wish to reassess during that clinic visit then repeat the CRM regardless of the findings (ie. even if DxHT is –ve)
- ‐ve DxHT because of successful manoeuvre or due to fatigued response that occurs naturally during repeated testing??
What are 3 situations when Brandt‐Daroff Exercises are used?
- CRT has failed
- Patient too anxious to consent to CRT
- if unsure of involved ear (Get them moving –> might get a clearer picture) Reposition manoeuvre
95% success rate in ____ -____ days in Brandt‐Daroff Exercises.
3‐14
Crystals get reabsorbed and go away between 14-21 days
What are the parameters for Brandt‐Daroff Exercises?
- 5 – 10repetitions / 3 x day
- Continued until patient experiences 2 consecutive symptom free days
Brandt‐Daroff Exercises can be modified for treatment of _____ canal BPPV
horizontal
Same exercise as previously described without the head ______.
rotation
15 ‐20% recurrence rate for _____
BPPV
Multiple ____ involvement not uncommon with ageing
canal
To self‐manage if reoccurring, have patient exercise at home to decrease the chance of _____
recurrence
Brandt – Daroff exercises should have ___ cycles, once a day
5
CRM (self‐ Epley) should have ___ cycle, once a day
1
What are 4 situations to refer on in terms of possible BPPV?
- If you are not sure of BPPV diagnosis (Vestibular migraines –> central problem (not mechanical)
- If you have attempted to treat them for BPPV but the patient is not responding to treatment (within 3‐4 treatment sessions)
- Any neurological or audiology signs
- Refer on to appropriate person for full vestibular / medical/ neurological assessment
How should you go about BPPV?
