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Diagnosis & Treatment of BPPV Is Not
Always Easy Two More Demanding CaseStudies.
Dr John E FitzGerald
Consultant Clinical Scientist
Norfolk & Norwich University Hospital
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Benign Paroxysmal Positional Vertigo
(BPPV)- The Condition
Cause:Otoconia from the
gelatinous membrane of the
utricle or saccule in the
vestibular labyrinth of theinner ear, break free and
reach the semicircular canals
(most commonly the
posterior semicircular canal(Lanska and Remler, 1997).
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Benign Paroxysmal Positional Vertigo
(BPPV)- The Condition
Certain position changes cause
otoconia in the endolymphof the semicircular canal tomove, resulting in ahydrodynamic drag effect,causing the cupula to bedisplaced, resulting in achange in neural firing rate,inducing a true rotationalvertigo. (Canalithiasis hall
et al, 1979).
The subject feels a shortduration dizziness.
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Diagnosis
Presenting Symptoms
Short duration rotational vertigo when adopting specific
positions, (rolling to the affected side in bed, rising frombed in the morning, looking up, lying down)
Vertigo is of latent onset (however this may not always
be noted by the patient)
Vertigo adapts if the position is maintained
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DiagnosisA Positive Hallpike Manoeuvre
Rapidly move patient from a sitting position, with their head turned 45 to theright or left, to a lying position with the head tipped 45 below the horizontal
A classical positive response is defined as
a latent period before the onset of nystagmus;
geotropic rotatory nystagmus with adaptation within 40 seconds (anupbeating vertical component is also sometimes evident)
reversal of nystagmus on sitting up (not always evident)
fatiguing of response on repeated manoeuvres
duplication of the patients report of vertigo. A positive response is attributed to the under most ear
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Positive Response
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Case 1.
A 56 year old manReferred by GP with a 6 month history of
dizzy spells, especially when he puts his
head back
Seen in January 2003 for vestibular
assessment
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Symptoms:
Off work for several months
TRV lasting 20seconds provoked by lying
supine, rising from the supine, rolling left orright in bed.
Last occurred morning of test.Left sided headaches, started at same timeas dizziness (respond to headache tablets).
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Hallpike Manoeuvre:Right: Positive
Latent onset geotropic rotatory nystagmus with associated dizziness,adapted after approx. 10seconds BUT followed by an ageotropicrotatory nystagmus for a further 30seconds at least. On rising avertical nystagmus was observed but this adapted.
On repeat only a geotropic nystagmus was present which adaptedand associated with less marked dizziness
Left: Positive
Latent onset more prominent geotropic rotatory nystagmus,showed adaptation after 60 seconds. Very dizzy and nauseous.
Complete fatigue on repeat.
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Conclusion:
Bilateral BPPV, worse on the left ear
Due to nausea only a Left sided Epley was
performed
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1 week post treatment reviewConsiderable improvement on rising from bed
Headaches diminished
BUT dizziness still provoked by some movements
ENG No spontaneous or gaze evoked nystagmus.
Normal Smooth Pursuit & saccadic following
Hallpike Manoeuvre: Left Positive
Latent onset less prominent than previous week geotropic rotatory nystagmus,
showed adaptation after 30 seconds. Dizzy.
RightPositive Latent onset geotropic rotatory nystagmus with associated dizziness, BUT NO
ageotropic rotatory nystagmus this week.
Due to nausea the left Epley was conducted immediately from the supine position of the
Hallpike.
Right Epley also performed.
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Further Reviews
3 weeks post treatment Symptoms continue
Headaches returned
Positive Hallpikes left and right
Breathless on rising from right Hallpike reported breathlessness on walking Worries about losing job
Further left Epley performed, referred for MRI to investigate
central pathology and advised to seek cardiovascular and
respiratory investigations (weight gain noticed).
Referred back June 03
Diagnosed chronic obstructive airways disease (under treatment)
Normal MRI (of IAMs)
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Further ReviewsReviews June 2003 - Sept 2003
Dizziness induced by rolling to left side, looking up, rising frombed in morning. Feeling of loosing consciousness & sometimes
wooziness lasting all day.
Right Hallpike: Classic positive findings.Left Hallpike : Negative.
Repeat Right Epley Manoeuvres (x 3 occasions).
Brandt Daroff Exercises.Discharged accepting some improvement, but no complete
recovery.
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Case 1 Right Hallpike (June 2004)
10 Second latent onset
AGEOTROPIC
rotatory nystagmus
Duration 20 secondsOn rising Nil
Testing stopped due tonausea
Eyes Up
Patient Eyes left Patient Eyes Right
Eyes DownN.B. Image is a mirror reflection of patient
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Take a Valium!
5mg 2 hours before appointment
5mg before being seen
Advice on driving!
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Case 1 Right Hallpike (Sept 04)Latent Onset
Short duration dizziness
? Horizontal Nystagmus
?Vertical Nystagmus
Geotropic rotatory
nystagmus
Adapts within 20seconds
Eyes Up
Patient Eyes left Patient Eyes RightEyes Down
N.B. Image is a mirror reflection of patient
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Case 1 Right Hallpike
Geotropic rotatory
nystagmus
Adapts
On RisingDownbeating vertical
nystagmus
Adapts
Eyes Up
Patient Eyes left Patient Eyes Right
Eyes Down
N.B. Image is a mirror reflection of patient
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Case 1 - ConclusionsNystagmus is of a peripheral origin
Latent OnsetAdaptationPartial Fatigue
Reversal from upbeating to downbeating onrising
Where are the otoconia?
Posterior canal?
Horizontal Canal?
Anterior Canal?
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Case 2 - History
A 71year old lady
2 year history of TRV lasting seconds
Provoked by turning in bed either side,
sitting up, looking up, and general head
movements
Latent onset reported
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Case 2. Left Hallpike - down
Geotropic rotatory
nystagmus
BUT NO adaptation
after at least 80seconds
Eyes Up
Patient Eyes left Patient Eyes Right
Eyes Down
N.B. Image is a mirror reflection of patient
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Case 2. Left Hallpike - Up
Vertical downbeating
nystagmus
BUT NO adaptation
Eyes Up
Patient Eyes left Patient Eyes Right
Eyes Down
N.B. Image is a mirror reflection of patient
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Case 2. Right Hallpike - DownAGEOTROPIC
rotatory nystagmus
No adaptation within
60secondsLatent onset
Eyes Up
Patient Eyes left Patient Eyes Right
Eyes Down
N.B. Image is a mirror reflection of patient
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Case 2. Right Hallpike - UpVertical Downbeating
Nystagmus
NO ADAPTATION
Eyes Up
Patient Eyes left Patient Eyes Right
Eyes Down
N.B. Image is a mirror reflection of patient
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Test IndicationsCentral Pathology
Why?
Lack of adaptation of geotropic rotatorynystagmus in left Hallpike
Ageotropic rotational nystagmus in right Hallpike
with lack of adaptation.Maintained downbeating nystagmus on rising
from both sides
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Case 2 Other Test ResultsDownbeating vertical spontaneous nystagmus
Also present with left gaze, and down gaze
Enhanced with rightward gaze
Abolished with upward gaze
Caloric test: Balanced warm water irrigations
MRI: No CPA LesionVentricles normal size and shape, not
displaced. No intra-cranial abnormality
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Case 2 Possible IndicationsCentral Problem
Lower Medullary
Infarction (due to
enhancement ofdownbeating
vertical nystagmus
with lateral gaze,and abolition on
upward gaze)
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Summary
Consider Valium to help complete tests andpossible treatment.
Look for reversal of nystagmus on changingposition
Other tests should always be used in conjunction
with Hallpike Manoeuvre when nonstandardresults obtained
Cant treat everyone