Benign Paroxysmal Positional Vertigo

Amy Stinson

MS IV

Kansas City University of Medicine

BPPV

General Considerations History Anatomy Pathogenesis Clinical Evaluation Treatment Prognosis

BPPV

Most common cause of peripheral vertigo Most common identifiable cause – Head

trauma, 2nd – vestibular neuronitis Predisposing factors: infection, surgery, prolonged

bed rest, Meniere’s disease Usually idiopathic 50 – 70% Incidence 64:100,000 every year 20-30% of diagnosed vertigo

History

1921 – Barany 1952 – Dix and Hallpike 1969 – Schuknecht

Proposed posterior canal crista was source of dysfunction Loose otoconia from utricle deposited on cupula Cupulolithiasis Concluded that ampullofugal (excitatory) deflection of

posterior canal cupula accounts for nystagmus

History

1979 - Hall, Ruby & McClure BPPV results from deflection of posterior canal

cupula because of the motion of debris within the posterior canal

Canalithiasis This accounted for fatigability of nystagmus

1985 – McClure – horizontal canal BPPV 1994 – Brandt – anterior canal BPPV

Anatomy

Vestibular portion of CN 8 arises in Scarpa’s ganglion in internal auditory meatus

Peripheral processes of bipolar ganglion cells terminate in hair cells of sensory epithelium of the labyrinth

Hair cells sit on the surface of cristae Cristae ampullaris – SCC Maculae acousticae – utricle and saccule

Hair cells are covered by: Cupula - SCC Otolithic membrane - maculae

Brodel M: Three unpublished drawings of the anatomy of the human ear, Philadelphia, WB Saunders, 1946

Cristae Ampullaris of SCC

Maculae Acousticae of

Utricle and Saccule

Anatomy

Semicircular canals Ampullae senses head

turning – angular acceleration

Endolymph w/in canal causes cupula to move

deflection of hair cells sensation of rotation

Utricle and Saccule Maculae senses gravity

and head tilt – linear acceleration

Hairs are displaced in response to gravity on otoliths sensation of tilt

Anatomy

Barber HO, Stockwell CW: Manual of electronystagmography, St Louis, Mosby, 1976

Pathogenesis

Canalolithiasis Most widely accepted hypothesis of BPPV Otoconia become displaced from utricular macula.

Because the particles are heavier than surrounding endolymph, they tend to collect in the long arm of the posterior semicircular canal.

Once the particles clump into a sufficient mass, changes in head position cause gravitation of the particles hydrodynamic drag on the endolymph displacing the cupula

Pathogenesis

5 Typical Features of PC –BPPV 1. The canalithiasis mechanism explains the latency of

nystagmus as a result of the time needed for motion of the material within the posterior canal to be initiated by gravity

2. The nystagmus duration is correlated with the length of time required for the dense material to reach the lowest part of the canal

3. The upbeating (vertical) and torsional components of nystagmus are consistent with eye movements evoked by stimulation of the posterior canal nerve

Pathogenesis

4. The reversal of nystagmus when the patient returns to sitting upright position is due to retrograde movement of particles in PC lumen back towards the ampulla

5. The fatigability of nystagmus evoked by repeat Dix-Hallpike positional testing is explained by dispersion of particles within the canal

Pathogenesis

Horizontal(Lateral) Canal – BPPV 2 - 15% BPPV pts Idiopathic, minor head trauma, complication of Tx of

PC-BPPV Turning the head while supine evokes severe vertigo Cupulolithiasis plays a greater role Resulting nystagmus is horizontal

Geotropic – toward undermost ear Apogeotropic – beats away from undermost ear (rarer)

Pathogenesis

Pathogenesis

Anterior Canal – BPPV Similar provoking factors as LC and HC – BPPV Nystagmus is downbeat and torsional Latency, duration & fatigability are similar

Case

69 yo female c/o several months of episodic dizziness described as spinning and imbalance associated with severe nausea

Last episode occurred when she got out of bed and felt dizzy within seconds

She has awakened from sleep with a swimming sensation She has had spinning sensations lasting less than a minute

when reaching into an upper cupboard Pt admits to being a “fender bender” a few months ago while

snowbirding down in Florida

Case

Exam is normal except for paroxysmal positional upbeating and counterclockwise torsional nystagmus with Dix-Hallpike positioning to the right side

Canalith repositioning is performed with resolution of her nystagmus upon repeat positioning

Clinical Evaluation

50 y/o Female Recurrent episodes of vertigo lasting less

than one minute (usually a few seconds) Associated with change in head position Nausea and vomiting Symptoms may fatigue as day progresses Episodes can continue for weeks to months

Clinical Evaluation

Normal neurologic exam Normal hearing test and tympanogram No spontaneous nystagmus Dix-Hallpike test

1-2 sec latency of onset of vertigo and nystagmus Nystagmus is classically torsional (rotatory) with vertical

component (counterclockwise for right ear and clockwise for left ear)

Nystagmus is fatigable with repeated tests

Dix-Hallpike Test

Clinical evaluation

Roll test Log roll or barbeque test Supine head turning elicits horizontal (lateral)

canal BPPV

Anterior canal BPPV most commonly spontaneously resolves

Treatment

Repositioning maneuvers Epley – effective in over 90% of cases

Most effective for PC-BPPV Sermont – more difficult to perform

No advantage over Epley After maneuvers, pts should avoid bending over

and should sleep with their head elevated at least 45° for the next 48 hrs

Epley

Sermont

Treatment

Surgical Singular neurectomy –

For Highly intractable BPPVThe post. ampullar br. of vestibular nerve is transected

just before it enters the amupllaComplete resolution in 80 – 97% of ptsSensorineural hearing loss 4 – 6%

Treatment

Surgical Posterior Semicircular Canal Occlusion

Obstruction of canal lumen preventing the flow of endolymph

This fixes the cupula and renders it unresponsive to angular acceleration

Post-op imbalance and disequilibrium and transient sensorineural loss that usually resolves within a few weeks

Prognosis

Natural history of BPPV includes acute onset and remission over a few months

90 – 95% of pts will respond to one repositioning maneuver

Pts can have unpredictable recurrences that often respond to a repositioning maneuver

With intractable disease posterior canal occlusion is safe and reasonable option

References

Cummings: Otolaryngology: Head & Neck Surgery, 4th Ed. UpToDate: Positional vertigo and nystagmus Fife, TD. Recurrent positional vertigo. Continuum: Lifelong learning in neurology. Aug 2006. 12:92-115. Quinn, FB. Ryan, MW. Medical management of vestibular disorders and vestibular rehabilitation. Grand

rounds, UTMB Dept. of Otolaryngology. 2004. Adams and Victor’s Neurology. Deafness, Dizziness, and Disorders of equilibrium. Chap 15. 2006. Lange Neurology. Disorders of Equilibrium. Peripheral vestibular disorders. Chap 3. 2006. Lange. Current Diagnosis and treatment of Otolaryngology – Head and neck surgery. Vestibular system.

Chap 43. 2004. Shaia, WT et al. Success of Posterior Semicircular Canal Occlusion and Application of the dizziness

Handicap Inventory. Otolaryngology – Head and neck surgery. 2006. 134:424-430. White, JA. Oas, JG. Diagnosis and Management of Lateral Semicircular Canal Conversions during Particle

Repositioning Therapy. Laryngoscope. 2005. 115:1895-1897. Virre, E. Purcell, I. The Dix-Hallpike Test and the Canalith Repositioning Maneuver. Laryngoscope. 2005.

115:184-187. Woodworth, BA. Et al. The Canalith Repositioning Procedure for Benign Positional Vertigo: a Meta-

Analysis. Laryngoscope. 2004. 114:1143-1146.

References

Kos, MI. Et al. Transcanal approach to the Singular Nerve. Otology and Neurotology. 2006. 27:542-546.

Parnes, LS. Agrawal, SK. Diagnosis and management of benign paroxysmal positional vertigo. CMAJ. 2003. 169:681-693.

Walsh, RM. Bath, AP. Cullen, JR. Long-tern results of posterior semicircular canal occlusion for intractable benign paroxysmal positional vertigo. Clinical Otolaryngology & Allied Sciences. 1999. 24:316-323.

Sekine, K. Imai, T. et al. Natural History of benign paroxysmal positional vertigo and efficacy of Epley and Lempert maneuvers. Otolaryngology – Head & Neck Surgery. 2006. 135:529-533.

White, JA. Coale, KD. Diagnosis and management of lateral semicircular canal benign paroxysmal positional vertigo. Otolaryngology – Head & Neck Surgery. 2005. 133:278-284.

Korres, SG. Diagnostic. Pathophysiology, and therapeutic aspects of benign paroxysmal positional vertigo. Otolaryngology – Head & Neck Surgery. 2004. 131:438-44.