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ORGAN SYSTEMS Otolaryngeal system (ENT)

Benign paroxysmal positional vertigo (BPPV)

Peripheral vestibular end‐organ disease typified by a sudden, transient gyratory sensation accompanied by characteristic nystagmus.

Introduction

Peripheral vestibular end‐organ disease typified by a sudden, transient gyratory sensation accompanied by characteristic nystagmus.

  • M/C peripheral vestibular end‐organ disease
  • M/C cause of vertigo (up to 20%)

History:


Physiology

Vestibular system:

to perceive head motion and position
  • Otolith organs (comprised of utricle & saccule): Detect linear acceleration and gravitational forces
  • Semicircular canals: Detect rotational acceleration
  • Endolymph hydrodynamics (within semicircular canals + influence on ampullary cupula): Sensation of angular movement in each of the 3 planes in which the canals are oriented

The symptomatology of BPPV is a direct result of aberrant semicircular canal signalling which creates an illusory sense of motion.


Aetiology

  • Idiopathic (M/C)
  • Head trauma
  • Ear infections

Pathophysiology

BPPV occurs due to the displacement of calcium-carbonate crystals or otoconia within the fluid-filled semicircular canals of the inner ear. These otoconia are essential to proper functioning of the utricle of the otolithic membrane by helping deflect the hair cells within endolymph, which relays positional changes of the head including tilting, turning, and linear acceleration.

With BPPV, otoconia (also known as “otoliths” or “canaliths”) dislodge and settle within the endolymph of the semicircular canals. When the head remains static, there is no stimulus causing the hair cells to fire. With motion, however, the displaced otoconia shift within the fluid, and the subsequent stimulus is unbalanced with respect to the opposite ear, inappropriately causing symptoms of dizziness, spinning, and/or swaying. Hence, symptoms of BPPV are profound with movement but classically lessen with rest.

Variants:

These two variants of BPPV means different characteristics of the nystagmus elicited by the provoking manoeuvres.
  • Canalithiasis (free-floating otoconia within canal duct)
    • Nystagmus; Brief (< 1 minute), paroxysmal and latency (few seconds)
  • Cupulolithiasis (otoconia adherent to the cupula)
    • Nystagmus: No latency and lasts long (> 1 minute)
Left inner ear: Demonstration of canalithiasis of the posterior canal and cupulolithiasis of the horizontal canal. | Parnes, Agrawal and Atlas. Diagnosis and management of benign paroxysmal positional vertigo (BPPV) Canadian Medical Association Journal September 30, 2003 169 (7) 681–693. © Canadian Medical Association 2003.

Classification

  • Posterior canal BPPV (pc-BPPV) (M/C variant, 80–90% cases)
  • Lateral canal BPPV (lc-BPPV)
  • Anterior/superior canal BPPV (ac-BPPV) (rare, 1–2% cases)
Diagnostic test, characteristics and treatment of BPPV types | a, anterior canal; h, horizontal canal; p, posterior canal. | Balatsouras DG, Koukoutsis G, Fassolis A, Moukos A, Apris A. Benign paroxysmal positional vertigo in the elderly: current insights. Clin Interv Aging. 2018;13:2251-2266 https://doi.org/10.2147/CIA.S144134

Clinical features

Classically, the symptoms of BPPV are sudden in onset, provoked by movement, and decreased with rest.

Rotational vertigo (M/C feature)

Brief, discrete episodes of vertigo lasting seconds to minutes upon lying down, turning over or getting out of bed
  • Severe cases associated with nausea & vomiting

Benign positional nystagmus:

Nystagmus direction, onset, intensity pattern and duration should be consistent with that expected of BPV

Diagnosis

Diagnosis of BPPV can be made based on the history and examination.

Dix–Hallpike maneuver:

Performed by rapidly moving head from upright to hanging position with one ear 45° to the side resulting in torsional upbeating nystagmus corresponding in duration to the patient’s subjective vertigo, and occurring only after Dix–Hallpike positioning on the affected side.

Supine head turn maneuver:

Diagnose horizontal BPPV by turning patient’s head to one side, then turning back to the supine face-up position. Then the head is turned to the other side. The nystagmus of horizontal canal BPPV, unlike that of posterior canal BPPV, is distinctly horizontal and changes direction with changes in the head position. The paroxysmal direction changing nystagmus may be either geotropic or apogeotropic.
Diagnosis of the involved semicircular canal and the side of involvement, according to the appropriate diagnostic maneuver | a, anterior; BPPV, benign paroxysmal positional vertigo; h, horizontal; L, left; p, posterior; R, right; SCC, semicircular canal. | Balatsouras DG, Koukoutsis G, Fassolis A, Moukos A, Apris A. Benign paroxysmal positional vertigo in the elderly: current insights. Clin Interv Aging. 2018;13:2251-2266 https://doi.org/10.2147/CIA.S144134

Differential diagnosis:

Clinical features of common causes of vertigo | Abhilash KP. Emergency Medicine: Best Practices at CMC. 2nd ed., Ch. 87, 282. New Delhi: Jaypee Brothers’ Medical Publishers; 2019.
Evaluation of a patient with vertigo. | Abraham SL. Primary evaluation and acute management of vertigo. Curr Med Issues [serial online] 2020 [cited 2020 Oct 24];18:217-21. Available from: https://www.cmijournal.org/text.asp?2020/18/3/217/289405

Management

The treatment of BPV involves positional manoeuvres to direct the displaced otoconia back into the utricle. For patients with the cupulolithiasis variant this will involve first converting to canalithiasis. The nystagmus observed during the manoeuvre can be a useful indicator of the ampullofugal flow of otoconia towards the utricle.

Accepted recurrence rate of BPPV after successful treatment is 40%–50% at 5 years of average follow-up. There does appear to be a subset of individuals prone to multiple recurrences.

Repositioning maneuvers:

Mainstay of treatment
Maneuver according each BPPV variant | Benign paroxysmal positional vertigo Diagnosis and treatment ITJ 2011 – Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Maneuver-according-each-BPPV-variant1-14-23_tbl3_264275132 [accessed 24 Oct, 2020]
“DizzyFix” dynamic visual device for teaching the modified Epley CRP to patients and health professionals. It is not a model of the semicircular canals but a representation assisting accurate head positioning and appropriate timing for a posterior canal particle to be successfully expelled. | Hornibrook, J. (2011). Benign Paroxysmal Positional Vertigo (BPPV): History, Pathophysiology, Office Treatment and Future Directions. International Journal of Otolaryngology, 2011, 835671. https://doi.org/10.1155/2011/835671

Epley maneuver:

Posterior canal BPPV treatment

Half-Somersault maneuver:

Posterior canal BPPV treatment

Gufoni maneuver:

Lateral BPPV treatment

Lempert (BBQ) maneuver:

Horizontal/lateral canal BPPV treatment

Deep head-hanging maneuver (DHM):

Superior/anterior canal BPPV

Other home exercises: CONTRAINDICATED

These are indicated in all causes of vertigo/diziness except those due to Meniere’s disease & BPPV

Vstibular suppressant therapy:

Cases with severe symptoms after a therapeutic maneuver, and patients who decline treatment although their symptoms are severe
  • Antihistamines
  • Benzodiazepines
  • Anticholinergics

Surgical management:

Central adaption and postoperative vestibular physiotherapy required in conjunction with procedures

  • Singular neurectomy (for p-BPPV): Transection of posterior ampullary nerve within singular canal (removes the resting input from the affected posterior canal ampulla, creating both a dynamic and static vestibular asymmetry)
  • Posterior semicircular canal occlusion (treat intractable BPPV): Occluding the canal renders cupulaunresponsive to stimulation from natural head movements or gravitational pull on the canaliths (the resultant dynamic vestibular asymmetry leads to an initial period of postoperative imbalance)

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