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BPPV Benign Positional Paroxysmal Vertigo

From Physiopedia

 

Welcome to PT 635 Pathophysiology of Complex Patient Problems This is a wiki created by and for the students in the School of Physical Therapy at Bellarmine University in Louisville KY. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!

Original Editors - Steve Blakely from Bellarmine University's Pathophysiology of Complex Patient Problems project.

Lead Editors - Your name will be added here if you are a lead editor on this page.  Read more.

Contents

Definition/Description

Though not fully understood, BPPV is thought to arise due to the displacement of otoconia (small crystals of calcium carbinate) from the vestibule of the inner ear into the fluid-filled semicircular canals. The posterior canal is the most commonly affected site, but the superior and horizontal canals can be affected as well[1].

The peripheral vestibular labyrinth contains sensory receptors in the form of ciliated hairs in the three semicircular canals and in the ear’s otolithic organs. They respond to movement and relay signals via the eight cranial nerve. Visual perception such as gravity, position, and movements also receive signals from somatosensory receptors in the peripheral vestibules. With the displacement of the otoconia into the semicircular canals, these delicate feedback loops relay conflicting signals.[2]


Prevalence

Dizziness is the complaint in 5.6 million clinical visits in the United States per year, and between 17 and 42 percent of these patients are diagnosed with BPPV.[3]

Prevalence has been reported at 10.7 to 64 per 100,000 population. Lifetime prevalence is 2.4 percent.[3]

Characteristics/Clinical Presentation

Symptoms of BPPV include:[4]

  • vertigo
  • lightheadedness
  • loss of balance
  • nausea
  • vomiting
  • nystagmus with positional change of the head

Each episode of BPPV should last no more than one minute.

Associated Co-morbidities[5]

  • Meniere's disease
  • Vertebral basilar insufficiency
  • Migrane
  • Multiple sclerosis

Medications

There are no medications that directly treat BPPV, only medications that can suppress the symptoms.[6]

Diagnostic Tests/Lab Tests/Lab Values

Dix-Hallpike test[3]
Dix-Hallpike Test
Dix-Hallpike Test
  1. To check for right involvement, rotate the patient's head to the right 45 degrees while in the long sitting position (this aligns the right posterior semicircular canal with the sagittal plane of the body).
  2. The examiner grasp the patient's head and quickly moves the patient to the supine position with the neck slightly extended (ear down position).
  3. The examiner checks for nystagmus. If present, note the latency, duration, and direction (should not last more than 1 minute). 


Electronystagmography[4]

Measures involuntary eye with the head placed in different positions or balance organs are stimulated.


Magnetic resonance imaging (MRI)[4]

Uses a magnetic field and radio waves to create cross-sectional images of the body. Would most likely be used to rule out acoustic neuroma or other lesions.

Etiology/Causes

Though the cause can often be unknown, degeneration of vestibular system of the inner ear is often problematic in older adults. Under age 50, head injury is a common cause. Vestibular viruses and Meniere’s disease also play a role. BPPV can also be a result of surgery due to prolonged supine positioning and possible trauma to the inner ear.[7]

Systemic Involvement

Fortunately, BPPV has very little systemic involvement. In serve cases of vomitting caused my BPPV, one may be at risk of dehydration.[4]

Medical Management (current best evidence)

This includes Canalith repositioning procedures, conservative treatments, and Semont maneuvers all in mentioned in Physical Therapy Management below. These techniques work for 80% of patients.[8]


For the other 20%, the best recommended surgery options is posterior canal plugging.[8]

Physical Therapy Management (current best evidence)

Canalith Repositioning Procedure[3]
Canalith Repositioning Procedure
Canalith Repositioning Procedure
  1. Patient starts in long sitting with the head rotated 45 degrees to the affected side. 
  2. Patient next rapidly reclined to the supine position with the neck slightly extended. This position is held for 30 seconds, or until nystagmus and dizziness subside.
  3. The patient's head is rotated 90 degrees to the opposite side. This position is held for 20 seconds, or until nystagmus and dizziness subside.
  4. The patient's head is turn another 90 degrees, requiring the patient to go from the supine to side-lying position. This position is held for 20 seconds, or until dizziness and nystagmus subside.
  5. The patient is brought up to the short-sitting position.


May need to complete this maneuver 1 to 3 visits complete resolution of symptoms.

Habituation techniques[7]

  1. Avoid quick spins or movements that provoke vertigo.
  2. Sleep in a semi-recumbant position for the next two nights following the above technique. In most cases a recliner works well, or stacking pillows at the head of the bed. Avoid sleeping on the affected side.
  3. Try to keep the head upright during the day, avoid all supine activities.
  4. After a week of being conservative, start to place the head (in controlled environments) in vertigo provoking positions.


Semont maneuver (home treatment)[3]
Semont Manuever
  1. Patient begins sitting in the short sitting position. The head is rotated 45 degrees towards the unaffected ear.
  2. The patient rapidly moves to side lying to the affected side (at this point to face should be oriented towards the ceiling). This position should be held for 30 seconds.
  3. Without any head movement, the patient is to move to side lying on the opposite side of the body (the face should be oriented towards the bed at this point). Hold this position for 30 seconds.


According to Bhattacharyya et al in a 2008 Otolaryngology-Head and Neck Surgery Journal, the Semont maneuver is more effective than Brandt-Daroff exercises. 

Clinician Videos

Dix Hallpike

[9]


Canalith Repositioning

[10]

Differential Diagnosis

Otological disorders include:[3]

  • Meniere's disease
  • vestibular neuritis
  • labyrinthitis
  • superior canal dehiscence syndrome
  • posttraumatic vertigo

Neurological disorders include:[3]

  • migraine-associated dizziness
  • vertbrobasilar insufficiency
  • demyelinating diseases
  • CNS lesions

Other possible causes are:[3]


[2]

Case Reports/ Case Studies

Epidemiology of benign paroxysmal positional vertigo: a
population based study

Effectiveness of Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo: A Systematic Review

Resources

Benign Paroxysmal Positional Vertigo (for the clinician and patient)

Clinical Practice Guideline: BPPV (for the clinician)

Effectiveness of Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo: A Systematic Review from PT Journal May 2010

Recent Related Research (from Pubmed)

    References

    see adding references tutorial.

    1. ↑ Dizziness-and-balance.com. Benign Paroxysmal Positional Vertigo. http://www.dizziness-and-balance.com/disorders/bppv/bppv.html (accessed 19 March 2011).
    2. ↑ 2.0 2.1 Sonia Sandhaus. Stop the spinning: Diagnosing and managing vertigo. Nurse Practitioner. 2002 Aug 1;27(8): 11-23. In: ProQuest Medical Library [database on the Internet] [cited 2011 March 19]. Available from: http://www.proquest.com/; Document ID: 154604631.
    3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 3.7 Bhattacharyya N, Baugh R, Orvidas L, Barrs D, Bronston L, Haidari J, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngology--Head And Neck Surgery: Official Journal Of American Academy Of Otolaryngology-Head And Neck Surgery [serial on the Internet]. (2008, Nov), [cited April 26, 2011]; 139(5 Suppl 4): S47-S81. Available from: MEDLINE.
    4. ↑ 4.0 4.1 4.2 4.3 Mayo Clinic: Benign Paroxysmal Positional Vertigo. http://www.mayoclinic.com/health/vertigo/DS00534 (Accessed 19 March 2011).
    5. ↑ Herdman SJ. Treatment of benign paroxysmal positional vertigo. Phys The 1990; 70:38l-388
    6. ↑ ENT Today. BPPV: State of the Art in Diagnosis And Treatment. http://www.enttoday.org/details/article/517121/BPPV_State_of_the_Art_in_Diagnosis_And_Treatment.html (accessed 4 Apr 2011).
    7. ↑ 7.0 7.1 American Hearing Research Foundation: Benign Paroxysmal Positional Vertigo (BPPV). http://www.american-hearing.org/disorders/benign-paroxysmal-positional-vertigobppv/ (Accessed 19 March 2011).
    8. ↑ 8.0 8.1 University of Maryland Medical Center: Hearing and Balance Center. http://www.umm.edu/otolaryngology/bppv.htm (Accessed 19 March 2011).
    9. ↑ ybdzy. Dix Hallpike. Available from http://www.youtube.com/watch?v=8NxjG80V7OU. Last accessed [4/26/2011].
    10. ↑ ybdzy. Canalith Repositioning. Available from http://www.youtube.com/watch?v=pIs2F2wiLwc&feature=related. Last accessed [4/26/2011].
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