Benign Paroxysmal Positional Vertigo

Aka: Benign Paroxysmal Positional Vertigo, Paroxysmal Positional Vertigo, BPPV

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II. Epidemiology

  1. Most common in ages 50 to 70 years old
  2. Female predisposition in older patients, but not in younger patients

III. Causes

  1. BPPV is Idiopathic in 50 to 70% of cases (esp. older patients)
  2. Ear Trauma (7 to 17% of cases) may precipitate BPPV
    1. More common in younger patients with BPPV
    2. Trauma may be associated with bilateral involvement
  3. Other causes
    1. Viral Labyrinthitis (15%)
    2. Meniere's Disease (5%)
    3. Migraine Headaches (5%)
    4. Inner ear surgery (1%)

IV. Pathophysiology

  1. Any of the three canals (posterior, lateral and superior/anterior) may be affected via canalithiasis or cupulolithiasis
    1. Posterior canal is affected in 90% of cases (typically canalilithiasis)
    2. Lateral canal is involved in 5-10% of cases (typically cupulolithiasis)
    3. Superior (anterior) canal involvement is uncommon
  2. Canalithiasis
    1. Free-floating endolymph debris collects primarily in the posterior canal due to gravity
    2. Trapped debris blocks the canal until it is cleared through the common crux
  3. Cupulolithiasis
    1. Temporary displacement of otolith (otoconia, canaliths) onto gelatinous capsule of the cupula
    2. Typically canaliths dislodged from vestibule into the posterior semicircular canal
    3. Symptoms persist until otolith (loose bodies) resorbed or repositioned into vestibule

V. Symptoms

  1. Severity
    1. Severe episodic Vertigo
  2. Provocative
    1. Only change of head position triggers Vertigo
    2. Provoked by turning onto one side (not the other)
    3. Vertigo with vertical head movements
      1. Provoked by extending neck while looking up
    4. Recurs with similar movement
      1. However, exhibits fatigability (effect diminishes with consecutive provocative maneuvers)
    5. Asymptomatic at rest
  3. Palliative
    1. Visual Fixation
  4. Duration
    1. Environment spins for 10-20 seconds (max of 60 seconds), then resolves
  5. Timing
    1. Symptom onset is delayed for seconds after the precipitating head movement (latency)
    2. Occurs at night while recumbent

VI. Signs

  1. Background
    1. Subjective BPPV may occur where maneuvers reproduce Vertigo, but Nystagmus is absent
    2. Treatment maneuvers (e.g. Epley Maneuver) may also be used diagnostically bedside
  2. Posterior Canal BPPV
    1. Dix-Hallpike Maneuver elicits symptoms when patient lies backward from seated position
    2. Rotary Nystagmus accompanies vertigo Sensation
  3. Lateral Canal BPPV
    1. Patient is Log Rolled (head and body) to one direction resulting in vertigo Sensation
    2. Horizontal Nystagmus accompanies vertigo Sensation
  4. Anterior Canal BPPV (Superior Canal BPPV)
    1. Patient lies supine with neck extended 30 degrees or more resulting in vertigo Sensation
    2. Vertical Nystagmus accompanies vertigo Sensation

VII. Precautions: Neurologic Red Flags suggestive of alternative diagnosis

  1. Dysarthria
  2. Diplopia
  3. Dysmetria
  4. Dysphagia
  5. Dysdiadochokinesia (DDK)
    1. Inability to perform rapid, alternating movements

VIII. Differential Diagnosis

  1. See Vertigo Causes
  2. Diagnosis of exclusion
    1. Rule out CNS and Ear organic disease
      1. BPPV is a Triggered Vestibular Syndrome and should not persist without provocation
      2. Acute Vestibular Syndrome (constant Vertigo), especially with positive HiNTs Exam is CVA until proven otherwise
    2. No Neurologic Red Flags (see above)
    3. Vertigo is classic for BPPV (see symptoms and signs above)
      1. Head movement consistently produces severe, brief Vertigo with rotary Nystagmus
        1. Dix-Hallpike Maneuver positive
        2. Contrast with Vestibular Neuritis which persists regardless of provocation
      2. Vertigo lasts <60 seconds, and exhibits latency and fatigability
      3. Visual Fixation and avoiding head movement are palliative

IX. Management

  1. Symptomatic Management
    1. See Vertigo Management
    2. Primary management is with Canalith Repositioning, not medications
    3. Exercise caution with medications due to risk of falls, and circumventing central compensation
  2. Posterior Semicircular Canal Maneuvers (90% of patients)
    1. Indicated when Dix-Hallpike Maneuver elicits Vertigo and torsional Nystagmus
    2. Canalith Repositioning Procedure (Epley Maneuver)
      1. As effective as medication therapy and recommended as part of acute medical care (including ED care)
      2. Successful in 70% of first trials (approaches 100% on further attempts)
      3. Hilton (2014) Cochrane Database Syst Rev (12):CD003162 [PubMed]
      4. Sacco (2014) J Emerg Med 46(4): 575-81 [PubMed]
    3. Brandt-Daroff Exercises
      1. Repositioning maneuvers performed by patient at home
        1. Mechanism may be to habituate to Vertigo rather than return canaliths to vestibule (Epley is preferred)
      2. https://www.youtube.com/watch?v=CTZfIv165sY
      3. http://www.ncuh.nhs.uk/our-services/brandt-daroff-excercises-quick-guide.pdf
  3. Lateral Semicircular Canal Maneuvers (5-10% of patients)
    1. Indicated when patient is Log Rolled (head and body) to one direction resulting in Vertigo and Horizontal Nystagmus
    2. Barrel Roll Maneuver
  4. Anterior Semicircular Canal Maneuvers (uncommon)
    1. Indicated when patient lies supine with neck extended 30 degrees resulting in Vertigo and Vertical Nystagmus
    2. Vertical Nystagmus is otherwise a sign of a cerebellar lesion (perform a careful Neurologic Exam)
    3. Deep Head Hanging Maneuver

X. Course

  1. Self limited
  2. Symptoms resolve in 4-6 weeks without maneuvers
  3. Prolonged disabling symptoms in 33% of patients

XI. References

  1. Arora and Menchine in Herbert (2014) EM:Rap 14(6): 2
  2. Baloh (1987) Neurology 37:371-8 [PubMed]
  3. Baloh (1999) Postgrad Med 105(2):161-72 [PubMed]
  4. Muncie (2017) Am Fam Physician 95(3): 154-62 [PubMed]
  5. Parnes (2003) CMAJ 169(7):681-93 +PMID:14517129 [PubMed]
  6. Rogers (2023) Am Fam Physician 107(5): 514-23 [PubMed]

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