W.M.C. Narampanawa

Vertigo -BPPV

The Ear

Definition An illusion or hallucination of movement which is usually rotational, either of oneself or the environment

A common problemMany different potential etiologiesSome time multifactorialDiagnostic & management challengeSome time unable to make definitive

diagnosis

Balance disorders

Vertigo – illusion of movements, usually rotational, can be an illusion of tilting or swaying

Pre syncope – light headednessDisequilibrium – general sense of imbalance on

walkingOthers –(psycho physiologic) difficult to

characterize

Dizziness – four basic types

Dizziness is a common presenting complaint

Dizziness may result from a disorder that affects any of the body parts involved in balance or from certain drugs.

The person's description of the problem and the results of a physical examination may suggest a cause, which may lead to additional tests.

Introduction

vertigo is the most common (40-50%)

Of the various causes of vertigo, benign positional vertigo (BPV) is the most common cause

Approximately 25-40% of patients who present with dizziness have BPV.

vertigo

Due to reduced blood flow to the entire brain and is classically described as feeling faint or lightheaded

Near-syncope

Is essentially a gait disorder Often caused by various neurological

problems like cervical spondylosis, extra pyramidal disease and

cerebellar diseasePatients typically describe their

dizziness only when walking.

Disequilibrium

This is the least understood and is thought to be due to altered central integration of sensory signals arising from normal end organs

Psychophysiologic dizziness

BPV was first described by Adler in 1897 and then by Bárány in 1922

Using positional testing, BPV can readily be diagnosed

BPPV/ BPV

B” = BenignNot a brain tumorCan be severe and disabling

BPPV

“P” = ParoxysmalEpisodic, not persistentHelpful feature in the differential diagnosis

BPPV

P” = PositionalOccurs with position of head

Turning over in bedLooking upBending over

BPPV

V” = VertigoAn illusion of motion“The room is spinning”Other descriptions

RockingTiltingDescending in an elevator

BPPV

Anatomy: UtricleUtricle

Connected to SCCContains

endolymphOtoliths (otoconia)

Calcium carbonate

Attached to hair cells

Macule (end organ)

Tells brain which way the head moves without lookingSCC: angular accelerationUtricle: linear acceleration

Vestibular system

Pathophysiology of BPPVOtoliths become

detached from hair cells in utricle

Inappropriately enter the semicircular canal

Normal situationAs one turns head to the rightEndolymph moves SCC receptors fire

“head turning right”Stop turning head endolymph stops

moving SCC receptors stop firing “head has stopped moving”

Physiology

BPPVStop turning head otoliths keep moving

drag endolymph receptors continue to fire inappropriately “head is still moving”

Eyes “head is NOT moving”

Brain room must be spinning in the opposite direction

Pathophysiology of BPPV

Incidence of BPV is 64 cases per 100,000 population per year (US)

Women are affected twice as often as men

in general, is a disease of elderly persons, although onset can occur at any age

Incidence

characteristically describe that the room or world is spinning

Diagnosis of posterior canal BPV is based on a characteristic history and a positive Hallpike test

Lateral Canal BPPV -Lateral Roll test

Diagnosis - History

Rolling over in bed Lying down Sitting up Leaning forward Turning the head in a horizontal plane

Vertigo may occur with

Symptoms are usually worse in the morning

Nausea is typically present (vomiting is less common)

individual episodes of vertigo in BPV last for seconds at a time

diagnosis of PC BPV is indicated by a positive Hallpike test

The neurologic examination is otherwise unremarkable

Diagnosis - Examination

Classic nystagmus occurs when the patient's head is dependent and turned to the affected side

The most common nystagmus seen is torsional or rotatory

Nystagmus usually occurs within 10 seconds after positioning but may present as late as 40 seconds

Dix - Hallpike test

Duration varies from a few seconds to a minute and associated the sensation of vertigo

Response fatigues if the patient is repeatedly placed into the provoking position

Dix – Hallpike test

Caution: For patients with cervical spondylosis

warn the patient that symptoms of vertigo

Instruct the patient to keep his or her eyes open no matter how bad he or she feels

Avoid in pts with IHD

Hallpike test

Hallpike testSeat the patient

close enough to the end of the table

lies supinehead should be

extended backward an additional 30-45°.

Hallpike testTurn the patient's

head 45°This position

orients the head such that the posterior semicircular canal is going to be in the same plane as the upcoming head movement

Hallpike testlay the patient

down until the head is dependent

This step does not need to be performed rapidly.

Check for reproduction of symptoms and nystagmus

the fast phase of the nystagmus should be upbeat (toward the forehead)

Hallpike test

Return the patient to the upright positionNystagmus may be observed in the

opposite directionPatient may describe that the world is

spinning in the opposite direction The neurologic examination findings

should be otherwise normal; if not, strongly consider alternative diagnoses

Hallpike test

Horizontal Canal BPV

Lateral Roll test Body supine

Head inclined 30º

Turn head to either side

2 variantsGeotropic

Apogeotropic

Geotropic LC BPPVFree particles in the

long arm of the LSC (Canalolithiasis)

Horizontal Ny. towards lowermost ear

Stronger Ny. on turning towards side of lesion.

Apogeotropic LSC BPPVCupololithiasisHorizontal

Ny.awayfrom lowermost ear

Stronger Ny. on turningaway from side of lesion.

Positional vertigo

Onset Sudden Slow, gradualIntensity Severe Ill definedDuration Paroxysmal ConstantNausea Frequent InfrequentCNS signs Absent Usually

presentTinnitus/hearing loss

Can be present Absent

Nystagmus Torsional/horizontal

Vertical

Nystagmus Fatigable Non-fatigable

PERIPHERAL CENTRAL

Idiopathic (50-60%) Infection (viral neuronitis) Head trauma, especially in younger

patients Degeneration of the peripheral end

organ Surgical damage to the labyrinth

Causes

MigraineLabyrinthitisMeniere’s diseaseVestibular neuronitisStroke Acoustic schwanoma

DD

Chronic otomastoiditisMedications (alcohol, phenytoin,

diuretics, salicylates, quinidine, quinine, barbiturates, antibiotics)

OtosclerosisOtotoxicityPosttraumatic injuriesVertebrobasilar insufficiency

DD

No pathognomonic laboratory test for BPV exists

Currently, no imaging study can demonstrate the presence of otoliths

Head CT scanning or MRI is indicated if the diagnosis is in doubt

Investigations

Epley maneuver Medical treatment is generally

ineffective but may be used to lessen the symptoms.

Management

Ongoing CNS disease (ie, stroke or transient ischemic attack [TIA])

Unstable heart diseaseSevere neck disease (eg, rheumatoid

arthritis) or history of cervical spine fracture or surgery

Carotid bruit on examination indicating carotid stenosis

Body habitus preventing performance of the maneuver.

Epley maneuver Contraindications

Goal is to move the otoliths out of the posterior semicircular canal and back into the utricle where they belong

The success rate of the Epley maneuver is very high (approximately 85-90%)

Epley maneuver

The head must be in the dependent (head-hanging) position

Maintain each position until the symptoms and nystagmus have disappeared (at least 30 seconds)

If the patient cannot tolerate the maneuver because of vomiting or severity of the vertigo, premedicate with a vestibular sedative

Epley maneuver general guidelines

Epley maneuver steps

patient sit upright on the bed with the head turned 45° to the affected side

Epley maneuver steps

Place your hands on either side of the patient's head and guide the patient down with the head dependent (as in the Hallpike test).

Epley maneuver steps

Rotate the head 90° to the opposite side with the patient's face upward and be sure to maintain the head-dependent position

Epley maneuver steps

Ask the patient to roll onto his or her side while holding the head in this position

Then rotate the head so that it is facing downward (tell the patient to look to the ground).

Epley maneuver steps Raise the patient to

a sitting position while maintaining head rotation

sitting the patient up so that he or she is sitting with his or her legs hanging over the edge of the bed

Epley maneuver steps Simultaneously

rotate the head to a central position and move it 45° forward.

Lempert(Barbecue) Maneuver

Common Maneuvers for LSC BPPV

generally ineffective but may be used to lessen the symptoms

natural history of BPV is to resolve with time as the otoliths eventually dissolve while in the semicircular canals.

Medical treatment

antihistaminic antiemetics Benzodiazepines Anticholinergics Sympathomimetic vestibular suppressants

Drug Category

Patients with persistent vomiting or intractable vertigo may require admission for hydration and vestibular suppressant medication.

Surgical elimination of posterior canal function is restricted to rare cases of long-standing refractory BPV.

Admission

Head exercise therapy (positional exercises of Brandt and Daroff, Casani’s, Appiani’s) that promotes central accommodation may be helpful for BPV

Avoid provocative movements (and limit activities)

Further Care

Tends to resolve spontaneously after several weeks or months

May experience recurrences months or years later

Prognosis

Thank you