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Vertigo, Benign Paroxysmal Positional (BPPV)
Chirag N. Shah, MD
Kyung In Yoon, MD
image BASICS
DESCRIPTION
  • Benign paroxysmal positional vertigo (BPPV) is a mechanical disorder of the inner ear characterized by a brief period of vertigo experienced when the position of the patient's head is changed relative to gravity.
  • The brief period of vertigo is caused by abnormal stimulation of ≥1 of the 3 semicircular canals of the inner ear, with the posterior canal most commonly affected.
  • BPPV is the single most common cause of vertigo.
EPIDEMIOLOGY
  • The lifetime prevalence of BPPV is 2.4%, and the 1-year incidence is 0.6%. The age of onset is most commonly between the 5th and 7th decades of life, and the incidence of BPPV increases with each decade of life, peaking in the 6th and 7th decades.
  • Prevalent sex: female > male
  • BPPV affects the quality of life of elderly patients and is associated with reduced activities of daily living scores, falls, and depression.
Prevalence
  • Common
  • 2.4% with one year incidence 0.6%
ETIOLOGY AND PATHOPHYSIOLOGY
  • In BPPV, calcite particles (otoconia) that normally weight the sensory membrane of the maculae become dislodged and settle into the semicircular canal, changing the dynamics of the canal. Reorientation of the canal relative to gravity causes the otoconia to move to the lowest part of the canal, causing displacement of the endolymph, deflection of the cupula, and activation of the primary afferent. This results in the generation of nystagmus and the associated sensation of vertigo.
  • BPPV may be idiopathic, posttraumatic, or associated with viral neurolabyrinthitis.
image DIAGNOSIS
  • The diagnosis is established based on history and findings on positional testing, clarified by Dix and Hallpike in 1952 (1,2)[A].
  • Positional tests place the plane of the canal being tested into the plane parallel with gravity.
PHYSICAL EXAM
  • The Dix-Hallpike Test (DHT) is used to diagnose BPPV (1)[A]. The test provokes the characteristic nystagmus associated with the symptoms of vertigo. For the DHT, the estimated sensitivity is 79% (95% CI 65-94) and specificity is 75% (95% CI 33-100) (3)[B].
  • To perform the DHT, the patient is positioned in long-sitting on the exam table with the knees extended. The head is then rotated 45 degrees toward the side to be tested. The patient is then lowered quickly to supine with the head 30 to 40 degrees below the horizontal, over the edge of the exam table. The position is maintained for a minimum of 45 to 60 seconds.
  • For each position, the clinician notes the direction of the fast phase of the nystagmus and the latency and duration of the nystagmus.
Posterior canal BPPV:
  • In the head-hanging position, the otoconia move away from the ampullary organ resulting in upward ipsi-torsional nystagmus.
  • The superior poles of the eyes beat up toward the forehead and rotate toward the lower-most ear, the involved ear
  • On return to the seated position, the otoconia move toward the ampullary organ resulting in the nystagmus reversing direction.
  • The latency of onset of nystagmus is 1 to 45 seconds, and the duration is usually <1 minute.
  • The nystagmus fatigues (reduction in the severity of symptoms) with repeated positioning.
Horizontal canal BPPV
  • Directional-changing positional nystagmus is observed in the test positions; the eyes will beat linearhorizontal toward the ground (geotropic nystagmus) or beat toward the sky (apogeotropic nystagmus).
  • One position may illicit a stronger nystagmus response. The side with great intensity indicates the side involved with geotropic lateral canal BPPV and the uninvolved side with apogeotropic lateral canal BPPV.
Anterior canal BPPV
  • In the head-hanging position, the nystagmus is downbeating and torsional, with the top of the eye torting away from the lower ear.
  • Usually caused by “canal switching” from canalith repositioning procedure (CRP) maneuvers
  • No further testing is indicated unless the diagnosis is uncertain, or there are additional symptoms and signs unrelated to BPPV that warrant testing.
DIFFERENTIAL DIAGNOSIS
  • Orthostatic hypotension and other disorders that cause low BP; symptoms usually occur when the patient stands up.
  • Damage to the brainstem or cerebellum can cause positional vertigo but is accompanied by other neurologic signs and usually has a different pattern of nystagmus.
  • Low spinal fluid pressure may cause positional symptoms that are better when the patient lies down.
  • Migraine-associated vertigo
  • Traumatic brain injury
image TREATMENT
  • The CRP or Epley maneuver is effective in the treatment of posterior canal BPPV (1)[A]. Using a particle repositioning maneuver, the clinician moves the patient through a series of positions. With each position, the otoconia settles to the lowest part of the canal. The debris is moved around the arc of the canal into the vestibule. In randomized controlled trials, the average short-term success rate of the CRP following one treatment session is 80 ± 9% (1)[A].
  • The clinician moves the patient through a series of four provoking positions:
    • 1) Placement of the right posterior canal (involved canal) in the right head-hanging position of the DHT
    • 2) The head is then rotated a total of 90 degrees toward the left (uninvolved side) into 45 degrees of left head rotation.
    • 3) Maintaining 45 degrees of left head rotation, the patient is rolled onto the left side (uninvolved side) with the head slightly elevated from the supporting surface.
    • 4) The patient then sits up and flexes the neck 36 degrees. Each position is maintained for a minimum of 45 seconds or as long as the nystagmus lasts. The procedure is repeated three times.
  • P.1117

  • CRP is the best maneuver for posterior BPPV and should be offered to all age groups (4)[A].
  • Semont maneuver is also another maneuver, less superior when performed alone (4)[A).
  • Contraindications are carotid stenosis, unstable cardiac disease, and severe neck disease. If the CRP is ineffective, self-administered CRP is performed at home (1)[A]. The patient performs the CRP on the bed with the head extended over the edge of a pillow. Better outcomes are achieved with a combination of CRP with self-administered CRP (1)[A].
  • CRP and Semont are ineffective for horizontal BPPV; variations of the Lempert maneuver, barbecue roll, or Gufoni maneuver are widely used treatment methods for horizontal BPPV.
  • Postmaneuver activity restrictions were previously advocated but in controlled trials it did not differ in clinical outcomes, which suggests that restrictions do not appear to affect the efficacy of positional maneuvers (2,4)[A].
MEDICATION
  • Vestibular suppressant medications are not recommended for treatment of BPPV, other than for the short-term management of vegetative symptoms (3)[A].
  • Antiemetics such as ondansetron (Zofran) may be considered for prophylaxis for patients who have had severe nausea or vomiting with the DHT.
  • Vestibular suppressants such as benzodiazepines and antihistamine anticholinergics such as meclizine should be avoided because they may suppress nystagmus during the DHT and treatment.
ISSUES FOR REFERRAL
Consider a referral to a specialist if BPPV is unresponsive to treatment or if the patient is diagnosed with atypical BPPV involving the anterior or lateral canal. Other maneuvers are available for treatment of typical and atypical BPPV. Consider referring to a physical therapist, otolaryngologist, or neurologist.
ADDITIONAL THERAPIES
  • Brandt-Daroff exercises and habituation exercises are not as effective as self-administered CRP. At 1 week, the average success rate for the Brandt-Daroff exercise is 23-24% compared with 90% for self-administered CRP (1,5)[A].
  • Surgical intervention is rarely indicated, except for refractory BPPV, and includes posterior canal occlusion and singular neurectomy.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
The patient should follow up within a week after treatment to ensure resolution.
PATIENT EDUCATION
A number of illustrative videos are available at www.youtube.com for education and self-CRP maneuvers.
PROGNOSIS
80% cure rate with CRP maneuvers, with a 30% recurrence rate at 1 year (6)[A], and 44% redevelop BPPV within 2 years (1)[A]
REFERENCES
1. Helminski JO, Zee DS, Janssen I, et al. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Phys Ther. 2010;90(5):663-678.
2. Devaiah AK, Andreoli S. Postmaneuver restrictions in benign paroxysmal positional vertigo: an individual patient data meta-analysis. Otolaryngol Head Neck Surg. 2010;142(2):155-159.
3. Halker RB, Barrs DM, Wellik KE, et al. Establishing a diagnosis of benign paroxysmal positional vertigo through the dix-hallpike and side-lying maneuvers: a critically appraised topic. Neurologist. 2008;14(3):201-204.
4. Fife TD, Iverson DJ, Lempert T, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008;70(22):2067-2074.
5. Amor-Dorado JC, Barreira-Fernández MP, Aran-Gonzalez I, et al. Particle repositioning maneuver versus Brandt-Daroff exercise for treatment of unilateral idiopathic BPPV of the posterior semicircular canal: a randomized prospective clinical trial with short- and long-term outcome. Otol Neurotol. 2012;33(8):1401-1407.
6. Smouha EE. Time course of recovery after Epley maneuvers for benign paroxysmal positional vertigo. Laryngoscope. 1997;107(2):187-191.
Additional Reading
&NA;
  • Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992;107(3):399-404.
  • Mandalà M, Santoro GP, Asprella Libonati G, et al. Double-blind randomized trial on short-term efficacy of the Semont maneuver for the treatment of posterior canal benign paroxysmal positional vertigo. J Neurol. 2012;259(5):882-885.
  • Radtke A, von Brevern M, Tiel-Wilck K, et al. Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure. Neurology. 2004;63(1):150-152.
  • Strupp M, Dieterich M, Brandt T. The treatment and natural course of peripheral and central vertigo. Dtsch Arztebl Int. 2013;110(29-30):505-515.
Codes
&NA;
ICD10
  • H81.10 Benign paroxysmal vertigo, unspecified ear
  • H81.12 Benign paroxysmal vertigo, left ear
  • H81.11 Benign paroxysmal vertigo, right ear
Clinical Pearls
&NA;
  • The diagnosis of BPPV is based on history and findings on positional testing (DHT).
  • The typical presentation is reports of transient episodes of vertigo (sensation that the room is spinning) associated with a change in position of the head relative to gravity.
  • BPPV may be treated effectively with particlerepositioning maneuvers in the office and at home.
  • Vestibular suppressant medications and antiemetics are not recommended for treatment of BPPV, other than for the short-term management of symptoms.