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Benign Paroxysmal Positional Vertigo
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Benign Paroxysmal Positional Vertigo
, Paroxysmal Positional Vertigo, BPPV
See Also
Vertigo
Vertigo Causes
Peripheral Causes of Vertigo
Central Causes of Vertigo
Vertigo Management
Meniere's Disease
Motion Sickness
Vestibular Neuronitis
Perilymphatic Fistula
(
Hennebert's Sign
)
Acute Labyrinthitis
Bacterial Labyrinthitis
(
Acute Suppurative Labyrinthitis
)
HiNTs Exam
(
Three-Step Bedside Oculomotor Examination
)
Horizontal Head Impulse Test
(
Head Thrust Test
,
h-HIT
)
Nystagmus
Skew Deviation
(
Vertical Ocular Misalignment
,
Vertical Heterotropia
,
Vertical Strabismus
)
Dix-Hallpike Maneuver
Dizziness
Dysequilibrium
Syncope
Light Headedness
Epidemiology
Most common in ages 50 to 70 years old
Causes
Idiopathic in >50% of older patients
Ear
Trauma
may precipitate (esp. younger patients with BPPV)
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
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
Visual Fixation
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
Signs
Dix-Hallpike Maneuver
elicits symptoms
Rotary
Nystagmus
accompanies vertigo
Sensation
Precautions
Neurologic Red Flags suggestive of alternative diagnosis
Dysarthria
Diplopia
Dysmetria
Dysphagia
Dysdiadochokinesia
(DDK)
Inability to perform rapid, alternating movements
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
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
Exercise
s
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
Course
Self limited
Symptoms resolve in 4-6 weeks
Prolonged disabling symptoms in 33% of patients
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]
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