Benign Paroxysmal Positional Vertigo (BPPV)
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1 Benign Paroxysmal Positional Vertigo (BPPV) Faints, fits and funny turns for the physician Monday 18 January 2016 Bristol Marriott Royal Hotel Dr Peter West, Consultant in Audiovestibular Medicine, Queen Alexandra Hospital, Portsmouth
2 CASE 1: 55 year old lady 4 week history sudden onset of imbalance feels constantly drunk Short bursts of vertigo especially when reaching up (hanging washing), bending down or getting up quickly Feels too dizzy to drive Intermittent tinnitus Chronic neck/back pain and stiffness: sleeps on 3 pillows Examination: Anxious. Tachycardia 100 BP 160/100 Wearing cervical collar, recommended by chiropractor. No response to The Four S s: Serc, Stemetil, Stugeron, Syringing
3 GP s conclusion I can only imagine it has got to be a mechanical neck problem because of the fact that it is only there in these positions.
4 GP referral to radiology for CT of balance mechanism or MRI of neck MRI of internal auditory meatuses: No abnormality MRI of cervical spine: Mild cervical spondylosis but no significant disc protrusion Conclusion: Not having found an adequate cause to explain her symptoms, it may be worth a return appointment for MR angiography of her carotid and vertebral arteries.
5 .... DIX-HALLPIKE TEST..
6
7 BPPV findings on Hallpike test Latent period: 2-40 secs Nystagmus: Upbeat and torsional to undermost ear Vertigo: usually severe, for duration of nystagmus Adaptation: resolves within 30 secs Reversal of nystagmus: on sitting up Fatiguability: goes away on repeating test Responds to CANALITH - REPOSITIONING (EPLEY) MANOEUVRE
8 Anatomy of the labyrinth Anterior semicircular canal Posterior semicircular canal Otolith organs Horizontal semicircular canal
9 Treatment of BPPV - Epley manoeuvre
10 (R) Epley manoeuvre Start: Head turned 45º (R)
11 (R) Epley manoeuvre 1. (R) Hallpike test: Head 45º (R), 30º down
12 (R) Epley manoeuvre 2. (L) Hallpike position Head 45º (L), 30º down
13 (R) Epley manoeuvre 3. On (L) side, 45º face down
14 (R) Epley manoeuvre 4. Sit up, keeping head turned (L)
15 (R) Epley manoeuvre 5. Head forward 30º
16 SEMONT LIBERATORY MANOEUVRE for (R) posterior SCC
17 (R) Semont manoeuvre 1. (R) Side-lying test
18 (R) Semont manoeuvre 2. Throw rapidly onto (L) keeping head turned to (L)
19 (R) Semont manoeuvre 3. Lying on (L) keeping head turned to (L)
20 BPPV characteristic symptoms - 1 Classical provoking movements: Lying flat Sitting up from lying flat Turning over in bed Looking up (extending neck) Bending down (flexing neck), especially to side
21 BPPV characteristic symptoms - 2 Vertigo: Usually rotational May be falling through bottom of bed On getting up, being thrown back onto bed Duration: Usually 5-20 seconds. Always under 1 minute May notice latent period of up to half a minute
22 BPPV characteristic symptoms - 3 Accompanying symptoms: NO neurological or audiological symptoms BUT BPPV may complicate other inner ear disease Pattern of attacks: Bouts: days, weeks or months at a time, with symptom free periods OR, may occur every day for years on end Constant unsteadiness rather than vertigo may be the main symptom
23
24 Not all positional vertigo is due to canalithiasis of the posterior SCC. (1) Cupulolithiasis Horizontal canal BPPV
25 Horizontal SCC BPPV No more than 5% of BPPV. Vertigo turning in bed (less on looking up). Roll test: Lie supine, one pillow Turn head sharply through 90º Transient vertigo with geotropic nystagmus Affected ear is side with worse symptoms/nystagmus Cupulolithiasis gives sustained, apogeotropic nystagmus. Treat canalolithiasis with BBQ manoeuvre
26 BBQ Roll manoeuvre for (R) Horizontal Canal BPPV 1. Lie supine. Roll head 90º (R) 4. Raised on elbows, keep head horizontal Best to use one pillow 6,7. Keep head turned (R)
27 Not all positional vertigo is due to canalithiasis of the posterior SCC. (2) Cupulolithiasis Horizontal canal BPPV Anterior canal BPPV
28 Anterior SCC BPPV Rare! Hallpike or Rose (Head-hanging) test: Nystagmus is downbeat with torsion to the affected ear Treat with: Epley manoeuvre (affected side) Reverse Semont manoeuvre (start nose down) Deep Head Hanging Manoeuvre
29 Physical therapy management of Anterior Canal Benign Paroxysmal Positional Vertigo by the Deep Head Hanging Maneuver Amer A. Al Saif, Samira Alsenany Journal of Health Sciences 2012; 2(4): 29-32
30 Not all positional vertigo is due to canalithiasis of the posterior SCC. (3) Cupulolithiasis Horizontal canal BPPV Anterior canal BPPV Central (cerebellar) disorders may be asymptomatic do a Hallpike in ALL cases of imbalance
31 Central (cerebellar) disorder? In (mainly) severe posterior SCC BPPV, there may be (mild) sustained downbeat nystagmus on the contra-lateral side. Debris in uppermost posterior SCC falls back onto the cupula. Resolves after successful Epley.
32 CASE 2: 59 year old man Admitted under cardiologists with dizziness. Referred with diagnosis of BPPV: Vertigo on lying down - 4 pillows - sleeps sitting up. Latent period. Vertigo lasts 5 minutes - stops when he sits up. Vertigo provoked by getting up and by bending. Balance generally not too bad.
33 Additional history: Lying flat induces breathlessness as well as vertigo. Symptoms helped by oxygen. Mild micturition syncope. Hallpike test: At 15 seconds, acute dyspnoea and vertigo. No nystagmus. At 40 seconds, had to sit up, inducing severe pallor and dizziness but no nystagmus. Outcome: Assessed (and turned down) for heart transplant.
34 Not all positional vertigo is due to canalithiasis of the posterior SCC. (4) Cupulolithiasis Horizontal canal BPPV Anterior canal BPPV Central (cerebellar) disorders may be asymptomatic do a Hallpike in ALL cases of imbalance Orthopnoea (!) Ultimately, diagnosis is by RESPONSE TO TREATMENT
35 the patient who fails to respond to Canalith Repositioning Manoeuvres (MAXIMUM of 3) MUST be referred for a specialist opinion
36 Portsmouth audit of BPPV new patients (no BPPV in previous year). Seen by 2 consultants (PW and Dr Victor Osei-Lah) over 2 years, Full data on 568.
37 Age range
38 in other words, BPPV accounts for AT LEAST 25% of all dizziness (presenting to a Balance Clinic) in the OVER-50s.
39 Duration of vertigo Duration Number % Less than 3 months % 3 12 months % 1 3 years 52 9 % More than 3 years % Unknown 23 4 %
40 Location of BPPV Type Number % Posterior SCC - (R) (L) Bilateral 34 6 Horizontal SCC - (R) (L) Bilateral 0 0 Anterior SCC - (R) (L) Bilateral 0 0 Mixed % 2.4% 1%
41 Aetiology No. % Migraine headache only 27 7 Migraine vertigo only Migraine both TOTAL migraine 15.7
42
43 Outcome after 1st treatment (568 cases) Success: 45% Partial success: 10% Failure: 6% Unknown: 39% Results in 261 cases with known outcome 1 st treatment success: 73% partial success: 17% failed: 10% After 2 nd treatment: 90% success
44 Recurrence rate 261 cases Recurrence Cumulative % 1 month 1 3 months months months months 23 2 years 26
45 Recurrent BPPV Recurrence is NOT a treatment failure, just bad luck. More likely if post-traumatic (may also be more resistant to treatment). Patients can be taught self-treatment. DizzyFIX ( 85 from fixear.com)
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