BPPV
- Vertigo - sensation of swaying, tilting, spinning or feeling unbalanced |
- Vertigo can be benign or sinister |
- Displacement of calcium carbonate crystals in the semicircular canals |
- The crystals settle in the endolymph
- No stimulus causing hair cells to fire
- displaced crystals shift with the fluid
Stimulus is unbalanced with respect to opposite ear
- This causes symptoms of dizziness/spinning/swaying |
Demographics
- Can occur at any age, but common at the 4th and 5th decade |
- Incidence increases over time because of the degenerative changes in the otolithic membrane (elderly can have falls) |
- Slightly more common in females |
- Affects right labryrinth more commonly |
Risk Factors
- Sedentary lifestyle |
- Nutritional deficiencies |
- Hyperinsulinemia |
- Hyperglycemia |
Ear Anatomy
- Filled with endolymph , endolymph bends cilia , movement of these cilia sends signals to brain
- Transmits to eyes and cervical proprioceptors
- Superior semicircular canal detects nodding movement
- Horizontal semicircular - right and left head rotation
- Posterior semicircular - Movement in coronal plane(lat flexion of head)
Causes
- Usually idiopathic (calcium carbonate particles dislodge and migrate into semicircular canals) |
- Cranial Trauma |
- Prior otological surgery |
- Infection |
- Vestibular neuritis |
- Middle ear disease |
- Menieres |
- Ovarian hormonal dysfunction |
- Ototoxicity |
- Endolymphatic hydrops |
- Syphilis |
- Psychological disorders |
- Vestibular system degeneration |
- Metabolic disorders |
- CV disease |
- Vertobrobasilar insufficiency |
- Vertebral artery stenosis and tortuosity |
Presentation
- Sudden episodes of rotatory vertigo |
- Usually lasts 10-20 seconds after head position change |
- Usually occurs during moving from upright to lying down. rolling from side to side in bed, bending forward, moving head to look up and downor side to side |
- Usually occurs with increased anxiety, impaired postural control, reduced quality of life |
- Rule out more sinister causes of vertigo/dizziness |
- Pinpoint site of involved canal (multiple can be involved and it can occur bilaterally) |
- Most cases affect posterior semicircular canal |
- +ve Dixhallpike ( for posterior reproduction of dizziness, nausea, and or upbeating rotary nystagmus (pupils move counterclockwise in right labryrinth lesions and clockwise in left) - Downward facing ear one being tested |
- +ve supine roll test (for horizontal canal) |
- Anterior canal is rare due to it's upright orientation (debris likely to fall out) |
Imaging
- MRI and CT/Not BPPV if:
Negative Dix-hallpike or supine roll
Abnormal cranial exam findings
Nystagmus (Vertical, torsional, direction-changing, non-fatigable - central cause)
Continuous symptoms
Head trauma
Vertigo occurs without changing head positions
Loss of conciousness
Frequent unexplained falls
Recent viral infection
Hearing loss
Tinnitus
Ear fullness
Earache
Ptosis
Facial/extremity paraesthesia
Visual disturbances
Difficulty swalling/speaking
Ataxia
medications (anti-hypertensive/anti-depressants) |
- This is to rule out other pathologies |
DDx
- Cervicogenic vertigo (similar to BPPV, patient complains of floating/lightheadness/unsteadiness, presents with loss of Cx ROM, Cx restrictions and tenderness +ve neck torsion test - stimulates cx proprioceptors) |
- Concussion (Trauma) |
- Intracranial Bleed (UMNL) |
- CNS ischemia/stroke/VBAI ( Gait, Ataxia, Rhomberg, coordinationother symptoms, Cranial nerves, blood pressure) |
- Neoplasm (Lymphnodes, systemic signs) |
- Infection (Temperature, Otoscopic exam, Lymph nodes) |
- Intracranial swelling |
- Migraine |
- Carotid sinus syndrome (Auscultation of carotid) |
- Intoxication |
- Menieres |
- Perilymphatic fistula |
- Vestibular system degeneration |
- CV disease (Heart and Respiratory exam) |
- Drug toxicity |
- Cerebellopontine angle neoplasm |
- Brainstem encephalitis |
Management
- Canalith repositioning and home exercises for appropriate semicircular canal |
- If posterior, Epley maneuver or Foster Half somersault |
- If horizonal canal, Lempert 360 roll maneuver (BBQ roll) |
- If anterior, Epley/reverse epley |
- Inform patients that they might feel dizzy, attempt to keep their eyes open as much as possible (look at my nose) |
- Inform patients to sleep with the affected side up and reaccurance rates (10 and 80% - delay between symptom and management leads to higher occurance rates) and safety |
- If CNS/balance disorders - additional home support to reduce risk of falling |
- Home exercises: Brandt-Daroff exercises, Foster half somersault, Eye tracking |
- Contraindications: Acute Cx F#/instability, recent cx spine surgery, perilymph fistula, Detached retina, Unstable carotid artery disease/stenosis, Vertebrobasilar insuffciency, Stroke/TIA, Unstable Heart disease, Severe neck disease (Cervical spondylosis +myelopathy, Advanced RA |
- Cx SMT |
- Antihistamines (Meclizine) suppress labryrinth excitability and vestibular-end organ receptors |
- Anti-emetics (ondansetron, metoclopramide, promethazine/prochlorperazine) |
Prognosis
- Most pts find relief within 4-6 weeks |
- Recurrence rates 5-25% |
- Risk of recurrence: Females, older patients, psychiatric |
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