BPPV

Notes

Overview

Benign paroxysmal positional vertigo (BPPV) is an inner ear disorder characterised by episodes of positional vertigo.

BPPV is the most commonly encountered cause of vertigo seen in clinical practice. It is caused by otoconia (loose debris composed of calcium carbonate) within the semilunar canals. Attacks are triggered by head movements that result in movement of the otoconia, abnormal motion of endolymph and the feeling of vertigo.

A careful history and examination are required to exclude other causes of vertigo. The Dix-Hallpike manoeuvre is used for diagnosis and manoeuvres such as the Epley can be used in treatment.

Epidemiology

It is estimated that the lifetime incidence of BPPV is 10%.

BPPV more commonly affects women than men with an overall prevalence of 11-140 per 100,000. It typically presents in between the fifth and seventh decade but may occur at any age.

Figures from NICE CKS.

Clinical features

BPPV is characterised by short episodes of positional vertigo typically lasting < 1 minute.

They are triggered by head movements or positional change. Specific movements such as turning over in bed may be identified as triggers. Nausea and vomiting may result from the vertigo.

Some patients may get symptoms that persist longer than expected, and other neurological causes must be considered and excluded.

Hearing loss and tinnitus are not features of BPPV and should raise suspicions of an alternative or concomitant pathology.

Diagnosis and investigations

Following a characteristic history and careful examination, the Dix-Hallpike manoeuvre is typically sufficient to diagnose BPPV.

Take a thorough history from all patients presenting with vertigo. Identify any features or risk factors that could indicate a more sinister cause. A careful ENT, cardiovascular and neurological examination is required. See our chapter 'differential diagnosis' for some alternative conditions to keep in mind.

Dix-Hallpike manoeuvre

There are a number of contraindications (relative and absolute) to the manoeuvre. These include neck trauma, spinal fractures, cervical disc prolapse, vertebrobasilar insufficiency, carotid sinus syncope, recent stroke or CABG, and back/spinal pain. If there is any doubt regarding the appropriateness of the test consult with a specialist.

Prior to beginning explain the procedure, the intended effects and the fact that it may trigger an episode of vertigo.

  1. Position the patient upright on a couch such that when lying supine their head hangs of the end of the couch.
  2. Ask them to turn their head 45o to one side and to keep their eyes open and look straight ahead during the manoeuvre.
  3. Supporting the head and neck, move the patient swiftly and smoothly from sitting to supine finishing with the head extended 30o below the horizontal plane of the couch.
  4. Observe the eyes for 30 seconds (there is often a latent period) for any nystagmus while continuing to support the head and neck. If nystagmus is present continue to hold the position for up to two minutes (as tolerated) and note the type and duration and any vertigo.
  5. Slowly return the patient to the sitting up position, again supporting the head and neck.
  6. Repeat the test with the head turned 45o to the other side.

The ear being tested is the one facing the floor. In BPPV the typical findings are transient vertigo and torsional nystagmus, which often follows a latent period and lasts 20-40 seconds.

Nystagmus that lacks a latent period, persists for longer than expected or is atypical in movement may need further investigation and should be discussed with specialists.

Check out this video from BMJ learning for a demonstration.

Other investigations

Typically additional tests are not required. However, in patients with an atypical presentation, negative/weak Dix- Hallpike manoeuvre or features that point to another neurological, cardiological or ENT cause additional investigations can be indicated.

MRI or CT head will generally be organised where another neurological cause is suspected (e.g. brainstem stroke, vestibular schwannoma).

Differential diagnosis

There are a number of differentials that should be considered in patients presenting with vertigo.

Peripheral causes

Peripheral causes of vertigo result from inner ear disorders that affect the vestibular nerve or labyrinth. Conditions include:

  • Vestibular neuritis (inflammation of the vestibular nerve thought to follow a viral infection, no hearing loss)
  • Labyrinthitis (inflammation of the labyrinth thought to follow a viral infection, also features hearing loss)
  • Ménière's disease
  • Vestibular ototoxicity
  • Perilymphatic fistula
  • Semicircular canal dehiscence syndrome

Central causes

Central causes of vertigo result from pathology affecting the brain, these are less common than peripheral causes. Conditions include:

  • Migraine
  • Stroke/TIA
  • Vestibular schwannoma
  • MS
  • Cerebellar tumour

Management

Management may be with watchful waiting or canalith repositioning manoeuvres to displace the otoconia from the semicircular canals into the utricle.

The patient should be counselled on BPPV and the treatment options. In the majority of cases episodes and symptoms resolve over several weeks (around 50% at 3 months). Recurrence is common affecting around half of patients with BPPV within 5 years.

As such watchful waiting may be used depending on patient preference. Canalith repositioning procedures like Epley’s are relatively straightforward and can rapidly resolve symptoms.

Falls risk should be established and measures to prevent or reduce the risk taken where necessary.

Canalith repositioning procedures

Canalith repositioning procedures can be used to treat BPPV. Epley’s manoeuvre is most commonly used, it aims to displace the otoconia from the semicircular canals into the utricle.

There are a number of contraindications (relative and absolute) to the manoeuvre. These include neck trauma, spinal fractures, cervical disc prolapse, vertebrobasilar insufficiency, carotid sinus syncope, recent stroke or CABG, and back/spinal pain. If there is any doubt regarding the appropriateness of the test consult with a specialist.

Prior to beginning explain the procedure, the intended effects and the fact that it may trigger an episode of vertigo.

  1. Position the patient upright on a couch such that when lying supine their head hangs of the end of the couch.
  2. Ask them to turn their head 45 degrees to the affected side.
  3. Supporting the head and neck, move the patient swiftly and smoothly from sitting to supine finishing with the head extended 30o below the horizontal plane of the couch.
  4. Wait for nystagmus and vertigo to resolve and for at least 30 seconds.
  5. Turn the head 90 degrees so the affected ear is now facing upward. Hold this position for around 30 seconds.
  6. Next ask the patient to roll to the same side their head is turned to. Continuing to support the head and neck turn so they a facing 45 degrees below the horizontal plane. Hold this position for around 30 seconds.
  7. Ask the patient to swing their legs over the side of the couch and sit them up slowly supporting their head and neck finishing in a position with the neck slightly flexed.
  8. Give the patient a moment to feel stable. Some people will advise patients avoid certain head movements for 24 hours but this is not typically felt necessary.

Check out this video from BMJ learning for a demonstration.

Other options include Semont manoeuvre and Brandt-Daroff exercises.

Driving

The Driver and Vehicle Licensing Agency (DVLA) advise all people with a 'liability to sudden and unprovoked or unprecipitated episodes of disabling dizziness' to stop driving and inform them. Generally, BPPV will considered provoked but consult with the DVLA where doubt exists.

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