Benign Paroxysmal Positional

Vertigo

Jeff Walter PT, DPT, NCS

Benign Paroxysmal Positional

Vertigo: (BPPV)

• Benign = not malignant

• Paroxysmal = recurrent, sudden intensification of symptoms

• Positional = placement (of ear)

• Vertigo = sensation of rotation

BPPV is the most common peripheral vestibular disorder

BPPV (cont)

• Patients tend to report complaints with:

– bed mobility (rolling or supine to sit)

– reaching for object on floor, under cupboard or

top shelf

– washing hair

– working under the car

– changing a light bulb

– dental chair

– diagnostic procedures involving head

dependency (CT, MRI, surgery)

Age Ranges Number of

patients

with BPPV:

Total: 71

Percentages

20-30 2 2.8%

31-40 0 0%

41-50 8 11.1%

51-60 10 13.9%

61-70 16 22.2%

71-80 23 31.9%

81-90 10 13.9%

91-100 2 2.8%

Data from 2005 at GHSRH (Walter, unpublished data)

• The prevalence of

BPPV to appears

increase with age

BPPV (cont)

• Primary Complaints

– poor balance

– vertigo

– difficulty walking

– lightheadedness

– nausea

– sense of tilt

– blurred/jumping vision

BPPV: Mechanism #1

• Cupulolithiasis (Schuknecht 1969): Otoconia

adherent to the cupula of the affected semicircular

canal. The canal becomes gravity sensitive which

is not the normal function of the semicircular

canals.

• Characteristics

– immediate onset of vertigo and nystagmus

– sx duration : long lasting, gradually decays over

a period of minutes

BPPV Mechanism #2

• Canalithiasis (Parnes and McClure 1992): Free

floating otoconia within the semicircular canal

resulting in abnormal endolymphatic flow with the

affected canal.

• Characteristics

– latency: range: 1 to 40 seconds, typically 3 to 5 seconds

– nystagmus and vertigo following the latency (5 to 45

seconds)

– reversal of nystagmus

– temporarily fatigues with repetition

Otoconia within the Posterior

Semicircular Canal (Parnes 1992)

Mathematical model for BPPV(Squires et al 2004)

Clinical Implications of

Mathematical Models for BPPV (rajguru 2004, squires 2004)

• Latency of BPPV is explained by movement of detached otoconia through the ampulla, as pressure caused by moving otoconia is negligible until otoconia enter the narrow duct of the semicircular canal. Typical otoconia move at a rate of 0.2 mm/s, or about 1% of the circumference of the canal each second.

• Particle-wall interaction accounts for the considerable variation in duration and latency of BPPV.

• Dispersion of a clump of otoconia creates more rather than less nystagmus. Thus, dispersion is not a viable explanation of fatigability.

• Cupulolithiasis is predicted to cause a far weaker nystagmus than canalithiasis.

• Inertial effects of treatment maneuvers cause negligible movement of otoconia.

Predisposing factors• Head trauma / sudden acceleration or deceleration of the

head (Gordon 2004)

• Inner ear disease

– Labyrinthitis

– Vestibular neuritis

– Ischemic event

– Meniere’s (Karlberg 2000)

– Bilateral incomplete ototoxicity (Black 2005)

– s/p stapedectomy (Magliulo 2005)

• Genetic (Gizzi 1998)

• Osteopenia / Osteoporosis (Jeong 2009)

Osteoporosis and BPPV (Jeong 2009)

Predisposing factors

• Sleeping position /

Prolonged immobility

– Cakir 2006 and Lopez-

Escamez 2005

• Affected ear in BPPV

correlated with habitual

ear dependency

– Von Brevern 2004

• Right BPPV > left

• (1.4 to 1)

Prevalence?

Oghalai et al 2000

• 9% with unrecognized BPPV in an inner-city geriatric population

• Patients with unrecognized BPPV were more likely to have:

– reduced activities of daily living scores

– sustained a fall in the previous 3 months

– depression

Von Brevern et al 2006

• Population-based study

• Utilized a validated

neurotologic interview for

detection of BPPV

• Lifetime prevalence: 2.4%

F>M

• Duration days to > than

months

Testing Maneuvers: BPPV

Posterior Canal

• Barany = Dix-Hallpike

= Hallpike

• Sidelying Test

Horizontal Canal

• Roll Test

What not to do with testing:

Sidelying Test to identify Posterior

Canal BPPV: position 2 = right, 4 = left

Sidelying vs. Dix-Hallpike

• Cohen HS. Side-lying as an alternative to the Dix-

Hallpike test of the posterior canal. Otol Neurotol. 2004

Mar;25(2):130-4.

1. Tests appear to have comparable sensitivity for

identification of BPPV

2. The sidelying test could be useful when range-of-motion

limitations or environmental limitations preclude use of

the Hallpike maneuver.

3. Consider the sidelying tests for pts with low back pain

“Roll Test” to Identify Horizontal Canal BPPV

• Performed to identify horizontal canal BPPV variant

• Head inclined 30 degrees from a horizontal plane

• Rotation performed ~60 degrees to each side, observe for nystagmus

• In patients with cervical ROM restriction consider rolling the patient from left to right with head fixed on the body

Physiology

• Utriculofugal cupular displacement is

excitatory for the anterior / posterior canal

and inhibitory for the horizontal canal

• Utriculopetal cupular displacement is

excitatory for the horizontal canal and

inhibitory for the anterior / posterior canal

Canal Specific eye movements:

slow phase component of VOR

• RPC = right posterior canal

• RHC = right horizontal

canal

• RAC = right anterior canal

• LPC = left posterior canal

• LHC = left horizontal canal

• LAC = left anterior canal

Review BPPV algorithm

Alternative causes of positional

dizziness / nystagmus

• Migrainous positional

vertigo

• Orthostatic

hypotension

• Tumor or CVA near

cerebellar vermis

• Superior Canal

Dehiscence

• Peripheral vestibular

hypofunction

• Phobia

• Vestibular Paroxysmia

Treatment = Maneuvers

• Evidence:

– Level A: American Academy of Neurology

(AAN) 2008

– American Academy of Otolaryngology:

“Recommendation” 2008

– Cochrane Database (Hilton 2004)

– Systemic Review (Helminski 2010)

• Vestibular sedatives are counterproductive

for BPPV (Manning 1992)

Canalith Repositioning Maneuvers

John Epley MD

“The canalith repositioning procedure: for treatment of benign paroxysmal

positional vertigo.”

Otolaryngol Head Neck Surg. 1992 Sep;107(3):399-404.

Modified Epley “Notes” for

Posterior Canal BPPV

• Nystagmus in positions “A, B and “C” of prior slides should be consistent; this is a positive prognostic finding of successful treatment. (Oh H, et al. Neurology 2007)

• Performance of a chin tuck in position “C” may assist in migration of otoconia toward the utricle.

• An absence of imbalance or vertigo with returning to a seated position after the maneuver is likely a positive prognostic finding of successful treatment.

• A reversal (unwinding) of nystagmus with returning to a seated position after the maneuver may be a negative prognostic finding, treatment should be repeated. (Oh et al)

“Semont” Maneuver for Right

Posterior Canal BPPV(Semont A. 1988)

• Originally developed for

cupulolithiasis

• Speed from position #2 to #3

is critical (Faldon 2008)

• Nystagmus in position #3

should be consistent with

position #2 (upbeating and

right torsion in this example)

Modified Gufoni’s Maneuver for the

Geotropic Variant of Left Horizontal Canal

BPPV, Canalithiasis type. (Appiani 2001)

• The patient sits on the side of a

treatment table with the head

straight ahead.

• The patient is steadily moved

into a sidelying position on the

unaffected side and remains in

this position one minute after

the end of the geotropic

nystagmus.

• The head of the patient is

steadily turned 45° downward,

and this position is held for two

minutes.

• The patient slowly returns to the

sitting position

Gufoni’s Maneuver:

References

Appiani CG. 2001

Francesco R 2009

Riggio F 2009

Brandt-Daroff Exercise for

anterior/posterior canal BPPV clockwise from the top

Alternative Devices

Post-maneuver instructions

• Head upright 1-5 days, sleep in recliner

Management guidelines

• Repeated examination may be required to confirm

BPPV (Pollack 2009)

• Pre-medication with vestibular sedatives (notably

Valium) may be helpful, especially for the patient with

high anxiety. Anesthesia can be considered in cases

involving patients with severe motion sensitivity.

• Do not leave patient during or immediately after

repositioning maneuvers. Approximately 13% of

patients may experience a strong falling sensation

during treatment (Uneri 2005)

• Vibration to the mastoid is used by some clinicians,

efficacy unclear. May aid in cases of “canal jam”?

Management Guidelines (cont)

• Patients may become ill during testing or

treatment, warn them beforehand

• Avoid prolonged dependency of affected ear,

especially if patient has a history of recurrent

BPPV

• Brandt exercises may be initiated 1-3 days after

treatment

– assess treatment effectiveness

– reduce patient anxiety

Management Guidelines (cont)

• Tilt table may be used

for the patient with

cervical limitations

Management Guidelines (cont)

• BPPV can occur bilaterally. Treat the most

symptomatic side first.

• Do not mistake BPPV with central

positional nystagmus

• Treat BPPV prior to initiating balance /

VOR exercises

Management Guidelines (cont)

• Follow-up visit

– Discuss presence of symptoms since initial

treatment session

– Review patient’s symptom diary (response to

Brandt exercises)

– Repeat Hallpike and Roll testing bilaterally

– Repeat canalith repositioning maneuvers if

indicated

Management Guidelines (cont)

• Follow-up visit (cont)

• Managed not cured

– Recurrence rate: (Hain, Helminski et al. 2000)

• One year: 25%

• Two year: 44%

• Instruct in self diagnosis and treatment if indicated

• Use of daily Brandt exercises does not appear to reduce

recurrence rate (Helminski 2005)

• Daily performance of maneuvers does not appear to reduce

the recurrence rate (Helminski 2008)

Self Treatment (Radke: Neurology 2004)

Efficacy• Canalith repositioning

manuevers (CRM)

– 70-95% resolution

• Gans & Harrington-

Gans 2002

• Korres 2004

• Macias 2000

• Nunez 2000

• Pollak 2002

• Roberts 2006

• Ruckenstein 2001

• Simhadri 2003

• Steenerson 2005

• Von Brevern 2006

• CRM typically

provides rapid relief of

symptoms

• Spontaneous

remission of condition

is common

Efficacy

Von Brevern et al 2006

• Evaluated the efficacy of Epley's maneuver for treatment of PC-BPPV 24 h after applying the maneuver.

• METHODS: Epley's maneuver was compared with a sham procedure in 66 patients with PC-BPPV by using a double-blind randomized study design.

Efficacy

• RESULTS: 24 h after treatment, 28 of 35

(80%) patients in the Epley's maneuver

group had neither vertigo or nystagmus on

positional testing compared with 3 of 31

(10%) patients in the sham group (p<0.001).