BENIGN PAROXYSMAL POSITIONAL

VERTIGO

Basic Anatomy

BPPV
Barany 1921
Dix-Hallpike 1952 important
features of nystagmus
Abnormal sensation of motion
elicited by certain critical positions
Provocative position nystagmus
At least 20% of vertigo
Underestimated
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BPPV
Subclassification : scc
post/lat/ant/bilat
Pathophysiology :
Canalithiasis
cupulolithiasis

Pathophysiology

Pathophysiology (cont.)
Cupulolithiasis :
Harold Schuknecht 1962
Densities (otocania) adherent to cupula
of crista ampullaris
Basophilic particles -1969

 Canalithiasis :
John Epley 1980
Densities free floating in canal portion
Parnes , McClure 1991 found particles
in post SCC

BPPV ...
Frequency : 10-64/100000
Sex : 64% women
Age : older population ( 51-57)
younger than 35 head trauma.
History :

sudden
days-weeks
occassionally months -years
episodes.

 Physical :
neurological examination normal
except Dix-Hallpike pathognomonic

BPPV
Nystagmus : characterization and
types
RT / LT , vertical / horizontal , changing
Tortional = Rotational clockwise /
counterclockwise
Geotropic- toward the earth
Ageotropic opposite

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BPPV
Classic post SCC geotropic rotatory
nystagmus
Horizontal SCC purely horizontal
nystagmus
Non-fatiguing nystagmus
cupulolithiasis > canalithiasis

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Classic BPPV
Involved the POST SCC
Geotropic NG with affected ear down
Rotatory , fast phase toward the
undermost ear
Latency few seconds
Duration limited < 20 seconds
Reversal upon return upright position
Response decline upon repetitive
provocation
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Lat. SCC PPV

Most common atypical BPPV

3-9% of cases
Consequence of Epley maneuver
Horizontal purely nystagmus
Cupulolithiasis rather than
canalithiasis
Modified Epley / lampert maneuver

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Lat. SCC PPV

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Ant. SCC PPV

Rare 2%
Down-beating /torsional NG for the
opposite ear on Dix-Hallpike
maneuver

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BPPV - Causes
Predisposing factors :
Inactivity
Acute alcoholism
Major surgery
CNS disease

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Causes ( cont. )
Idiopathic 39%
Ear disease 29%
OM 9%
Vestibular neuritis 7%
Meniers dis 7%
Otosclerosis 4%
Sudden SNHL 2%

Trauma 21%
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Causes ( cont. )

Trauma 21%
CNS diseases 11%
Acustic neuroma 2%
Cervical vertigo 2%

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BPPV - D.D

Meniers disease
Inner ear concussion
Alcohol intoxication
Labyrinthitis
Vascular loop syndrome
Post. Fossa lesions : acustic neuroma ,
meningioma
Central origion : stroke , MS , cerebellar
degeneration
Vertibral artery insuffeciency
Cervical vertigo
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BPPV - Treatment

Watchful waiting
Vestibular suppressant medications
Vestibular rehabilitation
Canalith repositioning
Surgery care

Labyrinthectomy
Post. Canal occlusion
Singula neurectomy
Transtympanic aminpglycoside application

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Trials about BPPV

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General
Labeled benign paroxysmal
positional vertigo is not always
benign
Evaluation of the effectiveness of
canalith reepositioning procedurs
CRP
Several studies

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Trials
Blakely 1994 :
50% improvement in the control and
CRP group !! ( 2-3 months)

Lynn 1995 :
Randomized-controlled : 89% negative
DH in CRP group , 27% in the control
group

John Li (1995) :
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Trials
John Li (1995) :
Comparison CRP / CRP + mastoid oscillation
and control
Modified Epley maneuver
Use of colar and head elevation after CRP
No spontaneous resolution within aweek
60% symptoms improvement in CRP group
92% symptoms improvement in CRP +mastoid
oscilation and 70% negative DH

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Trials
R. steenerson 1996 :
Comparison of CRP and vestibular
habituation training
Tow approaches are effective in
symptomatic relief ( 3 months)
CRP faster relief and fewer treatments

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Trials
K. Yimatae (2003)
Randomized-controoled
Modified Epley maneuver, no mastoid oscillator
and no instructions after the maneuver
Subjective and objective weekly follow-up
CRP group 76% negative DH, 48% control
group
CRP group 96% symptoms improvement ,
90% control group
Non-cured patients need > 6 procedures in 2
weeks , should considering liberatory maneuver
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Elderly population and BPPV

S. Angeli 2003 :
Effectiveness of CRP and VR
Modified Epley :
Elderly comorbidities : degenerative osteoarthritis
disease , CVA , peripheral neuropathy, cognitive and
autonomic dysfunctions
S/E of CRP neck torsion and extension result in
vertibrobasilar artery insufficiency, strain on the
spine column, dislodged carotid a. emboli
Avoid liberatory maneuver

64% CRP group negative DH after a month

Overall 77% with CRP and VR
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CRP Meta-Analysis
B. Woodworth - 2004

CRP - First line of treatment

Non-invasive
Easy to perform in the office
No need to expensive instrumentations
Repeat maneuver if needed
Potential to provide rapid relief of
vertigo

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Meta - Analysis
9 randomized-controlled trials
Symptoms resolution and elimination
of positive Dix-Hallpike test
CRP more effective than control ( x5 )
Untreated patients - symptoms
improvements with time but positive
DH
So Resolution of vertigo avoidance
of provocative positions
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CRP Epley maneuver

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CRP Semont maneuver

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Mastoid oscillator

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Brandt-Daroff Exsercise

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Lampert maneuver- Lat.

SCC BPPV

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Vestibular rehabilitaions

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Complications of CRP
Failure 25% (12%-56)
Recurrence 13% in 6 months
Side effects
Nausea
Vomiting
Fainting
Sweating

Worse vertigo LAT SCC PPV

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