II. Epidemiology
- Most common in ages 50 to 70 years old
III. Causes
- Idiopathic in >50% of older patients
- Ear Trauma may precipitate (esp. younger patients with BPPV)
IV. Pathophysiology
- Temporary displacement of otolith (otoconia, canaliths)
- Displaced onto gelatinous capsule
- Typically canaliths dislodged from vestibule into the posterior semicircular canal
- Symptoms persist until otolith (loose bodies) resorbed or repositioned into vestibule
V. Symptoms
- Severity
- Severe episodic Vertigo
- Provocative
- Only change of head position triggers Vertigo
- Provoked by turning onto one side (not the other)
- Vertigo with vertical head movements
- Provoked by extending neck while looking up
- Recurs with similar movement
- However, exhibits fatigability (effect diminishes with consecutive provocative maneuvers)
- Asymptomatic at rest
- Palliative
- Duration
- Environment spins for 10-20 seconds (max of 60 seconds), then resolves
- Timing
- Symptom onset is delayed for seconds after the precipitating head movement (latency)
- Occurs at night while recumbent
VI. Signs
- Dix-Hallpike Maneuver elicits symptoms
- Rotary Nystagmus accompanies vertigo Sensation
VII. Precautions: Neurologic Red Flags suggestive of alternative diagnosis
- Dysarthria
- Diplopia
- Dysmetria
- Dysphagia
-
Dysdiadochokinesia (DDK)
- Inability to perform rapid, alternating movements
VIII. Differential Diagnosis
- See Vertigo Causes
- Diagnosis of exclusion
- Rule out CNS and Ear organic disease
- BPPV is a Triggered Vestibular Syndrome and should not persist without provocation
- Acute Vestibular Syndrome (constant Vertigo), especially with positive HiNTs Exam is CVA until proven otherwise
- No Neurologic Red Flags (see above)
- Vertigo is classic for BPPV (see symptoms and signs above)
- Head movement consistently produces severe, brief Vertigo with rotary Nystagmus
- Dix-Hallpike Maneuver positive
- Contrast with Vestibular Neuritis which persists regardless of provocation
- Vertigo lasts <60 seconds, and exhibits latency and fatigability
- Visual Fixation and avoiding head movement are palliative
- Head movement consistently produces severe, brief Vertigo with rotary Nystagmus
- Rule out CNS and Ear organic disease
IX. Management
- See Vertigo Management
- Primary management is with Canalith Repositioning, not medications
- Exercise caution with medications due to risk of falls, and circumventing central compensation
-
Canalith Repositioning Procedure (Epley Maneuver)
- As effective as medication therapy and recommended as part of acute medical care (including ED care)
- Successful in 70% of first trials (approaches 100% on further attempts)
- Hilton (2014) Cochrane Database Syst Rev (12):CD003162 [PubMed]
- Sacco (2014) J Emerg Med 46(4): 575-81 [PubMed]
- Brandt-Daroff Exercises
- Repositioning maneuvers performed by patient at home
- Mechanism may be to habituate to Vertigo rather than return canaliths to vestibule (Epley is preferred)
- https://www.youtube.com/watch?v=CTZfIv165sY
- http://www.ncuh.nhs.uk/our-services/brandt-daroff-excercises-quick-guide.pdf
- Repositioning maneuvers performed by patient at home
X. Course
- Self limited
- Symptoms resolve in 4-6 weeks
- Prolonged disabling symptoms in 33% of patients
XI. References
- Arora and Menchine in Herbert (2014) EM:Rap 14(6): 2
- Baloh (1987) Neurology 37:371-8 [PubMed]
- Baloh (1999) Postgrad Med 105(2):161-72 [PubMed]
- Muncie (2017) Am Fam Physician 95(3): 154-62 [PubMed]