university of illinois HOSPITAL & health SCIENCES systeM

BPPV: Identification, Treatment and Differential Diagnosis

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Presented by Melissa Koehl, PT, OCS Sept 24, 2015

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What we will learnBPPV has a classic and easy to identify presentation 1. episodes of severe spinning vertigo ( 1 min = CUPULOLISTHIASISRARE! Consider other non-BPPV causes as wellNystagmus will have vertical AND torsional component toward the effected side. Named for the fast phase.

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Diagnostic Criteria for posterior canal bppv Subjective: repeated episodes of vertigo with changes in head position relative to gravityExam: Dix Hallpike1. Vertigo with nystagmus (vertical AND torsional) 2. Latency period ( 5-20 sec) prior to onset of vertigo and nystagmus 3. Vertigo and nystagmus increase then resolve in < 60 sec from onset of nystagmus

ALL of the above criteria must be present to definitively make diagnosisBhattacharyya et al 2008

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Special considerations are warranted in the geriatric population, because geriatric patients with BPPV usually report dizziness or imbalance and do not always describe a rotatory crisis. Batuecas-Caletrio and colleagues have argued that the Dix-Hallpike and supine roll tests should be performed in older patients with dizziness, despite the fact that they do not complain of spinning sensation with positional changes

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Treatment =

Canalith repositioningManeuver

Epley for posterior canal

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Canalith = Otolith

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Epley Maneuver

25Treatment for L posterior canal shown

Each position should be maintained for 30 sec or longer, after nystagmus and vertigo resolve

Epley maneuverFor treatment of Posterior Canal BPPVStart in sitting, head turned 45 toward the effected side.Quickly lay pt supine in 30 extension while maintaining 45 rotation toward effected sideTurn head 90 toward the unaffected earTurn pt to side lying while still in 45 rotation toward unaffected ear (pt looking at floor) Return to sitting at edge of bed while maintaining 45 rotation toward unaffected ear and chin tucked

Each position should be maintained for 30 sec or longer, after nystagmus and vertigo resolve26

Each position is maintained for about 30 seconds to allow the particles to move by gravity into a different part of the canal.26

prognosisVERY GOOD!

Meta-analysis: 81% recovery, compared to 37.% in placebo or untreated subjects (Helminski et al 2010)With repeated maneuvers in a single visit or repeated visits, remission is >90% (Lynn et al 1995)1 year recurrence rate 15% (Von Brevern 2007 )Referral to PT beneficial for repeated testing/CRM, treatment of residual balance deficits, motion sensitivity27

Higher recurrence in elderly (Batuecas et al 2013) and with head trauma (Liu 2012)

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BPPV CaseSubjective 59 y/o woman, insidious onset vertigo 2-3 wks agoDescribed as spinning vertigo. Intermittent. Lasts < 1 min Present when looking up, looking down and especially looking up and to the RAlso c/o constant woozy/drunk feeling that is worse when looking down 1 fall down the stairs due to vertigo while looking downHistory of congenital bilat low freq hearing loss, bilat tinnitus migraine HA (all unchanged since onset of vertigo)Occasional neck pain described as tension prior to migraine HA, not present recently Denies other central neurological or VBI symptoms

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BPPV Case ObjectiveGait wnl, no unsteadiness, ataxia or other gait deviations C-spine ROM wnl, no pain or dizziness all directionsVBI screen neg for dizziness or nystagmus (sustained seated cervical rotation) Occulomotor testing neg for central or peripheral dysfunction

Dix-Hallpike R: + robust vertigo and up beating/R torsional nystagmus, latency 2-3 sec, lasted < 1 min Dix-Hallpike L: +slight vertigo and up beating/R torsional nystagmus, latency 2-3 sec, lasted L)Eye movement ROM: WNLVergence: NTSmooth pursuit eye movements: negativeSaccadic eye movement: + on the R and LVOR Cancellation: WNLHead ThrustsHorizontal: consistently + to the R, IM + to the LStatic and Dynamic Visual Acuity: WNL, 7 lines in each condition

Easing: meclizine helps control the spinning sensation

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Complicated vestibular caseNeuro f/u appt found same CN findingsAdditional testing 3rd MRI subacute stroke L PICA territoryStandard angiogram 50% focal stenosis L VA intracranial segment, evidence of atherosclerotic disease

Medical Treatment: aspirin, atorvastatin, strict blood pressure and glucose control.

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Repeat MRI brain w/wo contrast with thin cuts through brainstem as well as base of skull. 66

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Complicated vestibular caseSymptoms improved with medical managementResumed outpatient PTAfter 7 days, pt had onset of episodic positional vertigoSeated head rotation no longer symptomaticOculomotor exam unchangedDix-Hallpike positive for classic BPPV with dizziness and L torsional upbeating nystagmus/dizziness