Benign Paroxysmal Positioning Vertigo

1. Benign Paroxysmal Positioning Vertigo Nancy Silbernagel, M.A., CCC-A HCMC Staff Audiologist

2. Definition Benign--not malignant or life threatening Paroxysmal--response (nystagmus) builds, peaks, fatigues Positioning--response provoked by change in head or body position Vertigo--sensation of movement, usually described as spinning or turning

3. Incidence Accounts for 20% of vertigo cases presenting to ENT office Frequently seen in elderly More frequent in females than males

5. Typical Presentation Transient episodes of vertigo (<1 minute) Initiated by position change Characterized by periods of exacerbation and remission Usually unilateral Little benefit from medication

6. BPPV Characteristics Lying down or getting up getting in and out of bed Rolling over in bed Bending over picking something up Looking up Shaving Washing hair in shower Going to dentist or beauty salon

7. Etiology Ideopathic Head trauma

8. Cupulolithiasis- -otoconia in the utricle break loose and adhere to the cupula of the posterior semicircular canal Canalithiasis--otoconia are free floating in the posterior semicircular canal; when the head moves into a provoking position, the otoconia sink into the most dependent position in the canal, causing endolymph to move

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10. Evaluation Dix Hallpike Patient sitting upright Turn head 45º to right Eyes remain open Assist patient into supine, head hanging position; maintain 45º head turn to right Patient focuses on target; observe eyes for nystagmus Maintain head hanging position for 30-40 seconds; if response occurs, wait for nystagmus to fatigue Patient centers head and returns to upright, seated position When seated, patient focuses on target; if response was demonstrated, may see nystagmus reversal Repeat with head hanging left Do not perform if positive vertebral artery screen.Do not perform if positive vertebral artery screen.

12. Diagnosis is based on a positive Dix-Hallpike Head hanging right- counterclockwise nystagmus Head hanging left-clockwise nystagmus (strong positional without complaints of vertigo is likely central)(strong positional without complaints of vertigo is likely central)

13. Classic Characteristics Latency-10-40 seconds Paroxysmal Rotary nystagmus Duration < 1 minute Fatigues with repetition Nystagmus may reverse in upright position

15. Management Nothing Medication is of little benefit Adaptation exercises (Brandt-Daroff) Surgery Canalith Repositioning Procedures Epley and Semont maneuvers Move otoconia from posterior canal into utricle (90% success rate) Surgery—posterior canal wall plugging --or severing vest. nerve --only small % considered for this surgerySurgery—posterior canal wall plugging --or severing vest. nerve --only small % considered for this surgery

16. Canalith Repositioning Procedure (CRP) Supporting patient’s neck, quickly assist patient into supine, head hanging position; maintain 45º head position Otoconia move toward center of PSC Without lifting the patient’s head, help patient turn head to the opposite Hallpike position Otoconia reach common crus Rotate head and body until patient is lying on side and nose is pointing to floor Otoconia pass through common crus Maintaining head position from #3, assist patient to a seated position Otoconia enter utricle Ask patient to center head and to tilt head down 20º Otoconia move into utriclear duct Repeat positions 1-5 until there is no nystagmus in any position Patient should remain in each position for latency + duration of nystagmus

17. Canalith Repositionging Procedure -note difference in Epley and CRP (no vibration in CRP, not medicated) -discuss modifications (pillow under shoulders, etc.)-note difference in Epley and CRP (no vibration in CRP, not medicated) -discuss modifications (pillow under shoulders, etc.)

18. CRP is only done when a positive Dix-Hallpike is observed Can’t base diagnosis on patient history alone Which ear will you treat? Acceptance of CRP has possibly lagged because patients were inappropriately treated; patient underwent maneuver, did not have BPPV, symptoms persisted, and CRP ruled unsuccessful

19. Semont -Rapidly moved from lying on one side to lying on the other -Often used in cupulolithiasis -When it doesn’t clear with CRP may try Semont—can also add head shake or vibration to CRP-Rapidly moved from lying on one side to lying on the other -Often used in cupulolithiasis -When it doesn’t clear with CRP may try Semont—can also add head shake or vibration to CRP

20. Patient instructions following CRP Sleep semi-recumbent for one night Avoid provoking head positions for one week Avoid moving head up and down Move head and body as a unit Can wear soft cervical collar as reminder for heard movement Do not sleep on the side that was just treated

21. Bilateral BPPV Much less common If you see it, usually will see with head trauma Must treat one side at a time so you don’t “undo” the side you just treated Harder to clear—generally will have multiple visits

22. Horizontal Canal BPPV Otoconia migrate to the lateral canal Less common than posterior canal BPPV Can happen after CRP if head is lifted between first and second positions Also can happen after home exercises—migrate into another canalAlso can happen after home exercises—migrate into another canal

23. Horizontal Canal BPPV Roll test Body supine Head inclined 30º Turn head to either side

24. Horizontal Canal BPPV Patients usually describe a strong and prolonged vertigo Often report dizziness when turning over in bed but not in other positions Can last up to or longer than a minute See a horizontal nystagmus, not rotary Nystagmus is typically present in both head positions but one is usually significantly worse Nystagmus can be geotropic or ageotropic Most commonly canalithiasis with geotropic nystagmus that is greater on the affected side

25. Maneuver for Horizontal Canal BPPV

26. Summary Etiology is ideopathic or head trauma Diagnosis is based on positive Dix-Hallpike CRP/Epley highly successful