bppv handout

8/10/2019 BPPV Handout

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Incidence/Prevalence of BPPV

• Most common referred diagnosis in tertiarycenters

• 9% of randomly selected community

dwelling elderly (Oghalai, J.S. et al 2000)• Incidence increases 38% with each decade

of life (Froehling 1991)



BPPV Basics

• BPPV most commonly affects theposterior semicircular canal.

• Observing nystagmus with Frenzel

lenses greatly assists in theidentification of involved canal(s)

• Supine head turns should be performedto check for lateral canal BPPV whenDix-Hallpike is negative.



Extraocular Muscles

Lateral Rectus

(abduction)

Medial Rectus

(adduction)

Horizontal

Canal

Inferior Oblique(elevation, out-

torsion)

Superior Rectus

(elevation, in-

torsion)

AnteriorCanal

Inferior Rectus

(depression,

some out-torsion)

Superior Oblique

(depression, in-torsion)

PosteriorCanal

ContralateralIpsilateralCanal



Nystagmus during CRP

• Nystagmus should remainipsidirectional during the procedure (i.e.if initial Dix-Hallpike positioning

provoked a right torsional nystagmus, itshould continue to be right torsionalthroughout the procedure)

• Reversal of nystagmus directionsuggests the particle has fallen backinto the canal and predicts failure.



Evidence Based Outcomes

• Controlled randomized and blinded studiesusing Dix-Hallpike as outcome consistentlydemonstrate 72% efficacy with a singlemaneuver (White et al, O&N 2004, meta

analysis of 9 studies and over 500 patients).

• Spontaneous resolution in contrast is only31% at 3 weeks.

• Canalith repositioning is “highly effective”based on number needed to treat, relativerisk reduction.



Lateral Semicircular CanalLSC-BPPV• Short latency horizontal nystagmus provoked

by supine bilateral head turns, with prolongedduration and poor fatigability.

• Uncommon (2-15% of total BPPV)

• Two forms

– Geotropic – beating towards undermost ear inright and left supine head positions

– Apogeotropic – beating away from undermost earin right and left supine head turn positions



Apogeotropic LSC- BPPV

• The affected side is usually moredifficult to identify – The side to which spontaneous nystagmus

beats if it is present (rarely observed)

– The side to which nystagmus is lessintense during positioning

– The side to which nystagmus beats when

the patient goes from sitting to supine(rarely observed)

Vannucchi, Asprella and Gufoni, 2005



Repositioning Maneuvers forApogeotropic LSC- BPPV

• Rapid supine head turn towards thegood side may mobilize debris in theproximal canal, converting nystagmus to

geotropic form (Asprella technique) andallowing repositioning

• Inverted Gufoni maneuver

– Patient lies quickly onto affected side andturns nose up for two minutes



Treating Posterior to Lateralcanal conversion

• Canal conversion confirms a mobileparticle

• Conversion involves the ear just treatedso the side of lateral canal involvementis certain

• Any of the lateral canal techniques will

work (Lempert, Vanucchi-Asprella)remember to rotate the head towardsthe good ear. 180 degrees will work ifutilized immediately.



Anterior Canal BPPV

• A rare and poorly understood type of BPPV

• May have a strong paroxysmal downbeatnystagmus in head hanging as the mainfinding (r/o 75% with central etiology)(Bertholon 2002, Crevits 2004).



Not So Benign PositionalVertigo

• Persistent positional nystagmus may

signify structural pathology



Persistent ApogeotropicNystagmus

• 50% of cases have associated caloric orvestibular test abnormalities

• Etiologies may include limited vestibular

neuritis (unilateral utricular nervesectioning in animal models producesapogeotropic positional nystagmus) or

structural abnormalities• Cerebellar degeneration (seen in older

adults)



Horizontal positionalnystagmus

• Low-amplitude (6 d/s or less) scatteredhorizontal positional nystagmus is anon-localizing, non-specific finding.

• Unidirectional nystagmus may be seenin vestibular neuritis (uncompensated),Meniere’s (to either the affected or

unaffected ear) or central pathologysuch as stroke, multiple sclerosis ortumor (acoustic neuroma or cerebellar).



Conclusions

• Semicircular canal variants andconversions are seen in about 20% ofcases. Supine head turn positioning is

helpful in diagnosing lateral semicircularcanal BPPV

• Examining the nystagmus during

repositioning allows for greater success• Persistent positional nystagmus

warrants further evaluation

bppv handout

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