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Benign Paroxysmal Positional Vertigo

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Benign Paroxysmal Positional Vertigo, Paroxysmal Positional Vertigo, BPPV

  • See Also
  1. Vertigo
  2. Vertigo Causes
  3. Peripheral Causes of Vertigo
  4. Central Causes of Vertigo
  5. Vertigo Management
  6. Meniere's Disease
  7. Motion Sickness
  8. Vestibular Neuronitis
  9. Perilymphatic Fistula (Hennebert's Sign)
  10. Acute Labyrinthitis
  11. Bacterial Labyrinthitis (Acute Suppurative Labyrinthitis)
  12. HiNTs Exam (Three-Step Bedside Oculomotor Examination)
  13. Horizontal Head Impulse Test (Head Thrust Test, h-HIT)
  14. Nystagmus
  15. Skew Deviation (Vertical Ocular Misalignment, Vertical Heterotropia, Vertical Strabismus)
  16. Dix-Hallpike Maneuver
  17. Dizziness
  18. Dysequilibrium
  19. Syncope
  20. Light Headedness
  • Epidemiology
  1. Most common in ages 50 to 70 years old
  • Causes
  1. Idiopathic in >50% of older patients
  2. Ear Trauma may precipitate (esp. younger patients with BPPV)
  • Pathophysiology
  1. Temporary displacement of otolith (otoconia, canaliths)
    1. Displaced onto gelatinous capsule
    2. Typically canaliths dislodged from vestibule into the posterior semicircular canal
  2. Symptoms persist until otolith (loose bodies) resorbed or repositioned into vestibule
  • 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
  • Signs
  1. Dix-Hallpike Maneuver elicits symptoms
  2. Rotary Nystagmus accompanies vertigo Sensation
  • 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
  • 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
  • Management
  1. See Vertigo Management
    1. Primary management is with Canalith Repositioning, not medications
    2. Exercise caution with medications due to risk of falls, and circumventing central compensation
  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
  • Course
  1. Self limited
  2. Symptoms resolve in 4-6 weeks
  3. Prolonged disabling symptoms in 33% of patients
  • 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]