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BPPV

Benign Paroxysmal Positional Vertigo

ByWendy Carender, PT, NCS

Advanced Vestibular Certified Physical Therapist

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Team of Audiologists at UMHS

Audiologists in Vestibular Testing Center

Assist in the Identificationof BPPV:

Dix-Hallpike and Positional Testing during VNG

Assist in the Managementof BPPV Perform particle repositioning maneuvers for simple cases

Patients are referred to Vestibular PT and/orOtolaryngologist for additional treatment anddiagnosis.

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BPPV ( Positional Vertigo)

Benign: not life threatening, however symptomsmay be intense

Paroxysmal : occurs suddenly

Positional: provoked by change in position ofthe head

Vertigo: sense of rotation or spinning usually

lasting less than one minute

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BPPV

Most common peripheral vestibular disorder

2.4% of all people will experience BPPV at some

point in their lifetime ( Fife TD, Inversion DJ, Lempert T.Neurology 2008)

Causes approximately 50 % of dizziness in older

adults ( Froehling DA, Silverstein MD, Mohr DN. Mayo Clinic Proc1991)

Increased risk of falling

Enormous Health Care Burden Estimated $2 billion per year

Easy to diagnosis and treat at the bedside

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BPPV Causes

Primary cause in people over age 50 is idiopathic

Primary cause in people under age 50 is headinjury

Increase frequency of BPPV found in patients withMigraine, Vestibular Neuritis and Meniere sDisease

BPPV occasionally occurs following other ear

surgery (stapedectomy) (AtacanE, Sennaroglu L,Dene A. Laryngoscope 2001)

BPPV may develop after long periods of inactivity

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BPPV H istory

History most importantpart of Vestibular Exam

First episode typically provoked by rolling over in

bed or getting out of bed

4 questions on Dizziness Handicap Inventory thatare helpful to screen for BPPV- Looking up cause dizziness

- Getting in/out of bed

- Rolling over in bed

- Bending over

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BPPV Anatomy

Vestibular organ: 3 semi-circular canals, utricle andsaccule.

Semi-circular canals: detect rotational movements and arefilled with endolymph

Ampulla: One end of each semicircular canal is widened toform an Ampulla

Cupula: sensory receptor located within the Ampulla

2 otolith organs measure linear acceleration and detect head

tiltUtricle (horizontally aligned) contains otoconia

Saccule (vertically aligned)

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Anatomy of the I nner Ear

Source of figures: Furman JM, Cass SP. Vestibular Disorders: A Case Study Approach, 2nded., 2003.

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Picture of Otol i thic Macula

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Otoconia

Otoconia: calcium carbonate crystals that areattached to the otolithic membrane in the utricle

BPPV occurs when otoconia detach from the

utricular membrane and migrate into the semi-circular canals.

Head movement otoconia shiftendolymph flow cupular deflection false

signal to brain vertigo and nystagmus.

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Direction of Endolymph F low is Important

Ampullopetalflow = flow towards ampulla (to seek)

In the horizontal SCC, this is excitatory. In the vertical canals, this isinhibitory.

Ampullofugal flow = flow away from ampulla (to flee)

In the horizontal canal, this is inhibitory. In the vertical canals, it is excitatory.

Ewald s Observations on

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Ewald s Observations onSemi Circular Canal Function

Eye movements occur in the plane of the SCCbeing stimulated AND in the direction of theendolymph flow

In the vertical canals, ampullofugal endolymphflow canals causes a greater response (eyemovements) than ampulopetal flow

In the horizontal canals, ampullopetal

endolymph flow causes a greater response thanampullofugal flow

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Figure source: Baloh RW, Honrubia V. Clinical neurophysiology of the vestibular system, 2ndedition. Philadelphia, PA: F.A. Davis Company; 1990.

Connections of SCCs with Extraocular Muscles

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Patterns of nystagmus associated with excitationof individual semicircular canals

Left posterior

Left superior

Left lateral

slow-phase fast-phase

up-counterclockwise

down-counterclockwise

left-beating

Medical Illustration Copyright 2009 Nucleus Medical Art. All rights reserved. www.nucleusinc.com

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2 Types of BPPV

Cupulolithiasis

Not as common

Otoconia adhere to the cupula

Immediate onset of vertigo and nystagmus when the

patient moves into the provoking position

Persistence of vertigo and nystagmus as long as the

patient remains in the provoking position (> 60 sec)

Important to differentiate between canalithiasisand cupulolithiasis to help guide your choice oftreatment

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Canal I nvolvement

Prevalence of BPPV (Fife and Lempert 2008)Posterior canal: 81-89%

Horizontal/Lateral canal: 8-17%

Superior/Anterior canal: 1-3% of cases

Video goggles used to record eye movement: (Imai etal 2005, Lopez-Escamez, et al 2005)

Posterior Canal: 41-65%

Horizontal canal: 21-33%

Superior canal: 17%

Multi-canal: 20% Common following head trauma.

Use Goggles for accurate diagnosis!

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Dix-H allpike Test (Barany Maneuver)

1952- Margaret Dix, MD and Charles S. Hallpike, MD

Gold standard test for diagnosis of posteriorsemi-circularcanal BPPV

Contraindications: severe RA, recent neck trauma or neck

surgery, vertebral basilar insufficiency, ChiariMalformation

Infrared Goggles to record eye movements or room light

To perform the Dix-Hallpike test, begin with patient long

sitting on the treatment table with head rotated 45

right orleft, then quicklygo to supine with head hanging slightly offthe table (20

extension).

Repetition of Dix-Hallpike results in fatigue of nystagmus

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Picture Dix-Hallpike Test

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Picture of Sidelying Test

To test the right ear,turn patient head 45to the left side andhave them quickly lay

down on their rightshoulder.

Wait at least 30seconds for any

nystagmus to appear.

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Pattern of Nystagmus for Positive Dix-Hallpike

Vertical Component Upbeating: posterior canal

Downbeating: anterior canal or possibly central

Torsional Component (named from patient perspective)

Right Hallpike: right torsion, clockwise, beating towards the dependent

right ear

Left Hallpike: left torsion, counter clockwise, beating towards the

dependent left ear

Horizontal Component: horizontal canal, perform Roll Test

Duration Less than 60 seconds: Canalithiasis

Greater than 60 seconds: Cupulolithiasis

Return to sitting: pattern of nystagmus reverses

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BPPV

Treatment options:Particle Repositioning Maneuvers (PRM): 75-80% success

rate in treatingposteriorcanal BPPV in one office visit.

Modified Epley (Canalithiasis)

Liberatory/Semont (Cupulolithiasis)

Brandt-Daroff Habituation Exercises.

Watch and wait: otoconia dissolve over time.

Caution patient to avoid provoking positions due to increased fall risk

Surgery: posterior canal plugging.

Medication: Vestibular Suppressants (Meclizine, Valium) are

typically not helpful since this is a mechanical problem.

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Treatment options-M aneuvers

Semicircular CanalInvolvement

Canalithiasisnystagmus< 60 seconds

Cupulolithiasisnystagmus> 60 seconds

Posterior- upbeating

torsional nystagmus

-Modified Epley (Particle

Repositioning Maneuver)

-Liberatory Maneuver

-Liberatory Maneuver

(mastoid vibration)

-Brandt-Daroff Exercises

Anterior- downbeating

torsional nystagmus

-Liberatory Maneuver

modified for AC

-Reverse Epley

-Liberatory Maneuver AC

(mastoid vibration)

-Brandt-Daroff Exercises

Horizontal- horizontal

geotropic or ageotropicnystagmus

-Lempert 360 BBQ Roll

-Appiani (modified Liberatory)

-Forced Prolonged Positioning

- Casini (Modified Semont)

-Brandt-Daroff modified for

Horizontal Canal

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Modif ied Epley Maneuver (Left Ear)

Wait dizziness PLUS 30 seconds in each position.

Eye movements should remain ipsi-torsional throughout the maneuver.

180 rotation of the head is required to effectively clear the debris(position B to D)

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Guidelines for a Successful PRM

Each position must be held a minimum of 30 seconds toallow the particle to settle ( Hain et al, 2004).

Perform at least 2 maneuvers within the treatment sessionto optimize outcome. Wait at least 2 minutes in-betweenmaneuvers.

Only treat one ear, one canal at a time (24 hour period)

Activity Restriction: patients without activity restrictionsrequired more treatment sessions (Cakir, et al 2006)

Sit for 15 minutes with head level in the clinic

Avoid bending over or laying flat the rest of the day (can

sleep in regular position at night)

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L iberatory/Semont Maneuver for Treatment ofPoster ior Canal BPPV (Cupuloli thiasis Variant)

Treatment shown for rightposterior canal

Turn head 45away from theaffected side (left)

Quickly lay on affected side (right)

and wait 1 minute

Quickly move the patient toopposite sidelying (< 1.5 seconds)without changing the head positionand wait for 1 minute

Slowly return to sitting with thehead level

Figure source: Parnes LS, Agrawal S, Atlas J. Diagnosis and management of BPPV. CMAJ 2003;169(7):681-693.

Additional Recommendations for

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Additional Recommendations forTreatment of BPPV

Patient with bilateral posterior canal BPPV: treatment ofchoice is Liberatory Maneuver to avoid triggering excessivenausea. Treat one ear per session.

Treatment for severe nausea: Zofran or Compazine prior tomaneuvers.

Use tilt table if patient has limited cervical extension.

Cupulolithiasis not responding to maneuvers: add mastoidvibration for 20 seconds in each position during maneuver.

Canal Conversion during PRM: 6% risk of conversion fromposterior to horizontal canal during the particlerepositioning maneuver.

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Brandt-Daroff Habituation Exercises

Not as effective as repositioning maneuvers (Cohen HS,Kimball KT. OtolNeurotol 2005;26: 1034-1040))

Mechanism

dislodges otoconia debris from the cupula

otoconia dissolve in endolymph central adaptation occurs so patient less symptomatic

5 Repetitions, 2x/day for 2 weeks

Figure source: Google Images

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Supine Roll test for Horizontal Canal BPPV

Supine Roll Test: tested in tranverse plane along thelongitudinal axis of the body with head elevated 20-30

0

neck flexion

Figure source: Heidenreich KD, Carender WJ, Heidenreich MJ, Telian SA. Annals of Vascular Surgery 2010; 24(4):553.e5.

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Roll Test for Hor izontal Canal BPPV

Roll Test is used for horizontal canal BPPV.Patient is supine with the head flexed 20. Head is

quickly turned to one side for 60 seconds andnystagmus is observed. Return to head center

position and wait a few seconds. Then the head isquickly turned to the other side for 60 seconds. Ifthe patient does not have full cervical rotation, thenhave the patient quickly roll onto their right or leftsides.

Similar to Head and Body Right/Left PositionalTesting

Horizontal/L ateral Canal BPPV

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Horizontal/L ateral Canal BPPVLateralization of Side of I nvolvement

Positive Roll Tests = horizontal nystagmus and vertigowould occur when the head is turned to both sides due to theco-planar orientation of the canals

Geotropic (towards the earth) Nystagmus:

debris located in the long arm of the horizontal canal

side of greatestintensity is the affected lateral canal

Ageotropic (away from the earth) Nystagmus:

debris attached to the cupula OR otoconia lie close

to the ampulated end of the canal.

side of lesserintensity is the affected lateral canal

Left Geotropic Horizontal Canal BPPV

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Left Geotropic Horizontal Canal BPPV

In left ear downposition, there is ampullopetalmigration of otoconia. This is excitatoryin the left HSC

and pt develops a Left Beating nystagmus.

In right ear downposition, there is ampullofugalmigration of otoconia. This is inhibitory,

and the pt develops a Right Beating nystagmus.

Figure courtesy of J.A White, MD, PhD

Geotropic HSC BPPV is due to canalithiasis where the otoconial

debris lies far away from the ampullated end of the canal.

Treatment of Geotropic Horizontal Canal

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Treatment of Geotropic Horizontal CanalBPPV Right Ear-Lempert BBQ Roll

270 -vs- 360 log roll- 30 seconds in each positionUse caution to avoid over rotation with the 360maneuver!

Modified Libertory maneuver (Appiani) for

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Modified Libertory maneuver (Appiani) for

Horizontal Canalithiasis (Geotropic)

Patient begins with head in a

neutral position and quickly

lies down on the unaffected

side and waits for one minute.

Patient turns head 45 degrees

downward and waits for one

minute.

Patient slowly returns to sitting

with their head level.

Treatment show is for the

LEFTearPhoto from Herdman 2007

Conversion of Ageotropic Nystagmus to

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Conversion of Ageotropic Nystagmus toGeotropic Nystagmus in H orizontal Canal

Head Shaking (Vanmicci et al 1992)20 head oscillations in the horizontal plane with the

patient supine and head tilted 30forward

Rapid Rolling (Lempert 1994)Rapidly roll from side to side 10 times.

Head Pitching ( Califano, et al 2008)

Pitch head 60

forward and 45

backward 20 times.

Modif ied Semont (Casini ) for Hor izontal

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Modif ied Semont (Casini ) for Hor izontalCanal Cupuloli thiasis (Ageotropic )

Patient moves quickly fromsitting with head in neutralto sidelying on the affectedside.

Head is immediatelyturnedso the nose is down 45.

Patient stays in this position for2 minutes, then slowly returnsto sitting.

Treatment shown for the rightear

Photo from Herdman 2007

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Factors Contr ibuting to Recurrence

Rate of recurrence is 15% per year, cumulative.

Rate of recurrence may be as high as 25% inthe first year, 44% in second year (Hain,Helminski, 2000)

Factors contributing to recurrence:

Head Trauma

A daily routine of Brandt-Daroff Exercise orEpley maneuver does not affect the time torecurrence or the rate of recurrence. Helminski JO, JanssenI, Hain TC. Otol & Nerotol 2008;29:976-981.

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Clinical Practice Guidelines: BPPV

Otolaryngology-Head and Neck Surgery 2008Recommended against full vestibular testing or

radiographic imaging in routinecases.

Dix-Hallpike and Positional Testing with Videogoggles

would be indicated if BPPV is suspected.

Recommend against treatment with vestibular

suppressants like benzodiazepines or antihistamines.

Recommend clinicians reassess BPPV patientswithin one month of treatment to confirm resolution.

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Modif ied Liberatory Maneuver

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Horizontal Canal BPPV

Positive Roll Tests = horizontal, bidirectionalnystagmus

Geotropic (towards the earth) Nystagmus:

side of greatestintensity is the affected lateral canal

Ageotropic (away from the earth) Nystagmus:

side of lesserintensity is the affected lateral canal

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Vestibular PT Evaluation (later same day)

Roll Tests in room lightRight Roll: left beating horizontal nystagmus lasting

> 60 seconds

Left Roll: right beating horizontal nystagmus lasting

> 60 seconds.

Nystagmus appeared to be of equal intensity to both

sides. Speed of the roll/head movement will affect

the response!Patient was more symptomatic when rolling to the

RIGHT side.