Benign paroxysmal positional vertigo

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Background

  • Abbreviation: BPPV
  • Due to canalolithiasis (migration of otoconia into one of the semicircular canals)
  • Mean age is mid-50s; women are twice as likely to be affected as men
  • Mean duration is 2 weeks

Clinical Features

  • Sudden-onset vertigo and associated nystagmus precipitated by head movements
    • Latency period <30s between provocative head position and onset of nystagmus
    • Intensity of nystagmus increases to a peak before slowly resolving
    • Duration of vertigo and nystagmus ranges from 5–40s
    • Repeated head positioning causes vertigo and nystagmus to fatigue and subside
    • Nystagmus reverses direction during the head down and head up portions of Dix-Hallpike
  • Nausea/vomiting common
  • Symptoms worse in the morning (symptoms fatigue as day goes on)
  • No associated hearing loss or tinnitus
  • MUST distinguish from central vertigo (HINTS Exam, Cerebellar stroke)

Differential Diagnosis

Vertigo

Evaluation

See vertigo for a general approach

Dix-Hallpike Maneuver

  • 50-85% Sensitive for BPPV[1]

Procedure

  • Patient sits upright
  • Patient's head is rotated to one side by 45 degrees. Then quickly lie the patient down
  • Maintain the head in 45 degree rotation but also 20 degrees of extension off the end of the table.
  • Observe the eyes for 45 seconds for nystagmus. There is often 15 seconds of latency prior to symptoms.
  • A positive test for BPPV is evidenced by the rotational nystagmus
    • fast phase of the rotatory nystagmus is toward the affected ear, which is the ear closest to the ground

Contraindications[2]

Management

Epley Maneuver[3]

Eply manuver
  • Epley begins after the last step of the Dix Hallpike
  • Patient remains in the position with exacerbated nystagmus for approximately 1–2 minutes.
  • Patient's head is then turned 90 degrees to the opposite direction so that the unaffected ear faces the ground
    • Maintain the 20 degree neck extension
  • Keep the head and neck in a fixed position while the patient rolls onto their opposite shoulder. The patient is now looking downwards at a 45 degree angle.
  • Keep the patient in the new position for 1 minute.
  • Finally bring the patient up to sitting while holding the head in 45 degree rotation.
  • May require multiple attempts, but you can discharge patient home with daily exercises
    • Improvement after x1 in 47% of patients, after x2 an additional 16%, and after x3 an additional 21%[4]

Medical management

  • Antihistamines
  • Anticholinergic
  • Benzodiazepines

Disposition

  • Consider referral to ENT for persistent symptoms despite treatment

See Also

External Links

References

  1. ↑ Sacco RR et al. Management of Benign Paroxysmal Posi- tional Vertigo: A Randomized Controlled Trial. J Emerg Med. 2014 Apr;46(4):575-81
  2. ↑ Humphriss, Rachel; Baguley D; Sparks V; Peerman S; Mofat D (2003). "Contraindications to the Dix-Hallpike manoeuvre : a multidisciplinary review". International Journal of Audiology 42 (3): 166–173.
  3. ↑ Hilton, Malcolm P; Pinder, Darren K (2004). "The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo". In Hilton, Malcolm P. Cochrane Database of Systematic Reviews
  4. ↑ Hughes D, Shakir A, Goggins S, et al. How many Epley manoeuvres are required to treat benign paroxysmal positional vertigo? J Laryngol Otol. 2015; 129(5):421-424.
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