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PC-BPPV

Using the Dix-Hallpike Maneuver in the directionof the involved ear canal (gold standard)

Mechanism: Otolithic debris away from the cupula

endolymph hidrodynamic drag stimulation of thecupula

Excitation of the posterior canal activation ofipsilateral superior oblique and contralateral inferiorrectus muscles upbeating and torsional nystagmus

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Special precautious: History of neck surgery Cervical radiculopathy Vascular dissection syndrome

The side-lying test may be used as analternative

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Dix-Hallpike maneuver

A. Seating the patient upright

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B. Head is turned 45 degree in the direction of the involved ear (B: right ear in this figure)

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C. The patient is then moved from the sitting to the supine position, ending with the headhanging at 20 degree off the end of table

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Side-lying Test

A. Seating the patient upright

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B. Head turned 45 degree angle away from involved ear

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C. Patient lies on the side of the involved ear

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HC-BPPV

Supine-roll test (Pagnini McClure maneuver) Nystagmus would appear:

Geotropic: beat toward the ground (canalolithiasis) Apogeotropic: beat toward the ceiling (cupulolithiasis)

Although difficult, it s important to determine itslateralization although difficult

Nystagmus appears stronger when head is turnedtoward the affected ear

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Other than the Pagnini, lying down nystagmus(LDN) or head-bending nystagmus (HBN) couldbe used as an alternative

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AC-BPPV

SHH as well as Dix-Hallpike maneuver oneither side may evoke downbeat nystagmuswith an ipsitorsional (upper poles of the eyesbeating toward involved ear) component.

The torsional nystagmus may not be asapparent as PC-BPPV

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Mixed-canal type of BPPV

BPPV may involve multiple semicircular canals PC- and HC- are the most common

combination MC BPPV frequently involves canals on the

same side Trauma may increase the risk of MC BPPV

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Differential Diagnosis

Posterior circulation stroke may mimic BPPV Lesions involving cerebellum

Central paroxysmal positional vertigo as aninfarction in dorsolateral to the fourthventricle or nodulus

Solitary plaque involving the brachiumconjunctivum