J Am Acad Audiol 4 : 384-391 (1993)

Benign Paroxysmal Positioning Vertigo with

Indeterminate Cerebellar Lesion : Case Report
Susan Lynn*
Robert Brey*

Abstract
Of the numerous causes of dizziness, those that represent a life-threatening condition are rare . Physicians
must
guard against missing these rare but serious conditions while controlling the cost of the evaluation of
patients
who present with dizziness . This case study involving a 41-year-old female was written to illustrate
the
importance of systematic case history taking and of obtaining an ENG. The patient presented with classic
symptoms of benign paroxysmal positioning vertigo (BPPV) . The managing physician performed an MRI, which
showed a cerebellar lesion . Results of a biopsy were negative . The patient's symptoms persisted, and she
travelled to our clinic for further assessment . An ENG demonstrated a classic response to the Dix-Hallpike
maneuvers, and a canalith repositioning maneuver was performed. The positioning dizziness resolved,
and
when contacted several months later, the patient stated she had remained asymptomatic .
Key Words: Benign paroxysmal positioning vertigo (BPPV), Dix-Hallpike maneuver, ENG, Epley
maneuver

enign paroxysmal positioning vertigo acterized by torsional nystagmus beating up

(BPPV) can be one of the easiest types
B of dizziness to detect and to alleviate.
The dizziness is easily reproduced during the
examination, with overt and specific signs.
Barany (1921) first described the syndrome,
which consists of a "burst" ofdizziness accompa-
nied by nystagmus, evoked exclusively by as-
suming specific head positions. Dix and Hallpike
(1952) listed specific criteria to be met before
applying this diagnosis . Their list included the
following: (1) a history of dizziness occurring
with head movements; (2) occurrence of dizzi-
ness accompanied by torsional nystagmus when
the head was moved into the offending position ;
(3) response latency of 5 to 15 seconds; (4) a
substantial diminution of the response within
30 seconds; (5) possible reversal of the nystagmus
upon return to the sitting position from the
offending position ; and (6) reduction in response
intensity upon repeat trials . Any patient whose
responses do not meet these criteria should not
be considered to have BPPV .
Using the recommended method of direct
observation of eye movements during the Dix-
Hallpike maneuver, the classic response is char-
*Department of Otorhinolaryngology, Mayo Clinic,
Rochester, Minnesota
Reprint requests : Susan Lynn, Eisenberg 3F, Mayo
Clinic, Rochester, MN 55905
and toward the undermost ear. Thus, head-
hanging-right produces counter-clockwise rota-
tory nystagmus and head-hanging-left produces
clockwise rotatory nystagmus . The response is
accompanied by dizziness, which duplicates the
patient's chief complaint. If the nystagmus is
purely rotatory, it is not recordable with con-
ventional electro-oculography, because the posi-
tively charged cornea and negatively charged
retina do not deviate horizontally during the
rotatory eye movement . In our experience, the
nystagmus can often be recorded in either the
vertical or the horizontal channel (or both),
because it is rarely purely rotatory. We have,
however, rarely evaluated anyone who became
dizzy during the left or right head-hanging
maneuvers who did not also have easily visual-
ized nystagmus at the same time . Therefore, we
routinely perform Dix-Hallpike maneuvers with
eyes open and fixed, in a lighted room . If the
patient's history is typical of BPPV, but the test
result is negative (i .e ., no dizziness and no
nystagmus), we ask the patient if dizziness was
expected with this type of movement . If the
response is affirmative, we repeat the Dix-
Hallpike maneuver, perhaps moving more
quickly and waiting longer in the head-hanging
position . Occasionally, a positive response is
then evoked. If not, the patient may be in a
period of spontaneous remission. It is then im-

384
 Benign Paroxysmal Positioning Vertigo/Lynn and Brey
portant to inquire about when the most recent
symptoms occurred .
Many patients with BPPV present with a
stereotypical description of brief, true vertigo
that occurs only with quick movements. Char-
acteristic situations when this might occur are
turning in bed or reaching up to retrieve some-
thing from a high shelf. Some clinicians advo-
cate performing the Dix-Hallpike maneuvers
only if the patient has a history suggesting a
position-related problem. In our experience,
however, BPPV patients may report atypical
types of dizziness or chronic imbalance as their
major complaint. They may initially deny hav-
ing any motion-related dizziness. After provok-
ing a positive Dix-Hallpike response, during
which the patient reports the typical "burst" of
dizziness, the patients often comment that they
do get this dizziness too, but that they are not
troubled by it, since they have learned to avoid
it . Other patients may report position-related
dizziness, but may describe the dizziness in an
atypical manner . Descriptions we have heard
include "floating," "sinking," "dying," or just
momentary lightheadedness . A physician or
audiologist might be easily misled by such de-
scriptions .
ETIOLOGIC CONSIDERATIONS
A n excellent review of BPPV was presented
by Mohr (1986) . He reviewed convincing
evidence suggesting that the posterior semicir-
cular canal is the specific site of dysfunction in
most patients with BPPV. Surgery to destroy
the function of the posterior semicircular canal,
either by plugging the canal or by severing the
posterior ampullary nerve, has been effective in
eliminating BPPV. Parnes and McClure (1991)
have described visualizing free-floating parti-
cles in the posterior semicircular canal during
canal-plugging surgical procedures . The exact
cause ofBPPV, however, remains undetermined .
Various investigators (Stahle and Terins, 1965 ;
Herndon et al, 1976 ; Katsarkas and Kirkham,
1978 ; Baloh et al, 1987) have examined coexist-
ing findings for groups of patients with BPPV .
While the vast majority have no other known
pathologies, some patients have a concurrent
diagnosis ofdisturbances such as endolymphatic
hydrops, acoustic neuroma, labyrinthitis, a his-
tory of head trauma, or surgical procedures . A
few have concurrent central problems . Animal
experiments have demonstrated paroxysmal po-
sitioning nystagmus subsequent to inducing
cerebellar lesions (Fernandez et al,1959) . There
is some question, however, as to whether the
resultant nystagmus is rotatory, with the upper
pole beating toward the undermost ear (Baloh
et al, 1979b) . Speculation that BPPV may have
central causes appears to be based upon the
coexistence of a lesion within the central nerv-
ous system, found at the same time the patient
complained of positional vertigo. Thus, there is
no strong evidence of any causal relationship
between a central lesion and BPPV.
A primary weakness in the evaluation and
diagnosis of these patients is that the definitive
criteria set forth by Dix and Hallpike have not
been strictly or rigorously applied by all inves-
tigators (Mohr, 1986). Another potential weak-
ness is that the examiner who evaluates the
patient makes the determination of these crite-
ria based upon subjective observations . The
subjectivity of these judgments may cause vari-
ation from examiner to examiner, based on their
experience in determining the direction of the
fast phase ofnystagmus and on patient coopera-
tion at the time of the test . Such problems must
be Dept in mind when reviewing records for a
given patient or when evaluating literature on
BPPV .
In our caseload, between 5 and 10 percent of
the patients have a final diagnosis of BPPV,
based upon a classic Dix-Hallpike response .
Other facilities report prevalences of 10 percent
(Drachman and Hart, 1972) to 17 .5 percent
(Barber, 1984). In view of the frequency of
occurrence and the wide variety of descriptions
of the problem, the Dix-Hallpike maneuver is
best used as a standard test in the assessment
of the dizzy patient. The procedure typically
takes less than 5 minutes to perform, and could
be performed as part of a routine clinical assess-
ment, as it requires no special equipment other
than an examining table.
Even though the demonstration of BPPV
with the Dix-Hallpike maneuver is straightfor-
ward for an experienced examiner, it is not
uncommon that patients who have complained
of positional dizziness have been misdiagnosed
or have remained undiagnosed. Such outcomes
occur in part because patients seek medical help
for their dizziness from physicians within a
variety of different specialties . Unfortunately,
physicians vary widely in their knowledge about
dizziness and its assessment . Some physicians
may not have easy access to objective tests of
vestibular function. Further, individuals per-
forming these tests (including audiologists) have
a wide range of skill in performing and inter-
preting the tests accurately.
Journal of the American Academy of Audiology/Volume 4, Number 6, November 1993

PATIENT PRESENTATION

n March of 1992, a 41-year-old female

came to our clinic after unsuccessful and
unusual evaluation and treatment for dizziness
elsewhere. She stated that in the spring or
summer of 1988, she had experienced brief
episodes of vertigo, as well as chronic, on-feet
imbalance, which disappeared in about 1 month
without treatment. In May of 1990, she experi-
enced a recurrence of the symptoms . Her dizzy
spells had never lasted more than a few mo-
ments and had always been precipitated by
motions such as rolling over in bed to the left
and getting out of bed in the morning. She
stated that her symptoms had not varied from
1990 to the time of our evaluation . She con-
sulted a physician in her home town, who or-
dered a magnetic resonance image (MRI) and an
audiogram, but no vestibular tests (Fig. 1) .
Audiometry indicated normal hearing, bilater-
Figure 2 MRI indicating a right cerebellar lesion just
ally . Contralateral acoustic reflexes were re- posterior and lateral to the fourth ventricle (see arrow) .
ported as normal .
MRIs were done in July of 1990 and in
March, May, and November of 1991 (Fig . 2) . All a stereotaxic biopsy of the lesion, which showed
MRIs demonstrated a lesion in the right cer- normal cerebellar tissue . Following the biopsy,
ebellum just posterior and lateral to the fourth her speech was slurred, and she noticed diffi-
ventricle with no mass effect, and there was no culty with her coordination . Her motion-related
enhancement with gadolinium . She underwent dizzy spells persisted.
Neurologic evaluation within our clinic
demonstrated normal mental status, language,
Frequency in Hertz blood pressure, and cranial nerve function. She
177 750 500 1000
1500
7000 7 .000 e~ 8000
had a slight dysarthria, and her muscle stretch
m reflexes were present. She also showed a termi-
a nal tremor and reduction of alternating motion
- ---- ---- ---- -+- -+-- ~- - E
O rates in the right upper extremity. Brainstem
auditory evoked potentials were normal . It was
70 2
u il ur ~'1 Z~l ' 1
z
S 50
concluded by the managing neurologist that the
- cerebellar lesion probably represented a con-
i
.0

genital cyst, which would continue to produce

no symptoms .
L 70 The patient was referred to our department
v
so for vestibular evaluation . Electronystag-
~ro
m
mography (ENG) and computerized dynamic
x 100 posturography tests were conducted (Fig . 3) .
110 The warm water caloric irrigations demon-
170
- 1 1
strated strong and symmetric responses (right,
67 degrees/sec, and left, 55 degrees/sec) . Gaze
testing, visual pursuit, fixation suppression,
Speech Audiornetry Signal : VILV, CID W-22
and ocular saccades were all well within normal
Speech Reception Thresholds : RT : 5 dB HL
LT : 5 dB HL limits (Fig . 4A-C). There was some mild, direc-
tion-fixed, right-beating positional nystagmus
Speech Reception Scores : RT : 100% Cad 40 dB SL
LT : 100% Ca3 40 dB SL with eyes closed and alerting in the supine,
head-left, and head-hanging positions (Fig . 5A-
Figure 1 Audiometric results, including pure-tone
thresholds and speech audiometry .
C) . The computerized dynamic posturography

386
 Benign Paroxysmal Positioning Vertigo/Lynn and Brey

28"1-92 Id : 188 Figure 3 Caloric responses for

warm water irrigations at 44°C
,Right Cool Peak SPU : *** */see -Left Warm Peak SPU : 55 */see for 30 seconds, using 250 mL wa-
80 -
ter.

0
W 40 -
0
} 20 -
f .
U
0-
J
W
D
W _20-
Q
Z
a -40 -

-80
Right Warm Peak SPU : -66 '/sec ,Left Cool Peak SPU : */see
0 20 40 60 80 100 120 029 4 . 6989109124
SECONDS SECONDS
Caloric Weakness "*"*
Directional Preponderance -

test was normal for both the motor and sensory
portions of the test (Fig. 6A, B) .
The Dix-Hallpike maneuver demonstrated
a classic response in the head-hanging-left posi-
tion . The response consisted of paroxysmal,
clockwise nystagmus, which began approxi-
mately 5 seconds after assuming the position .
The response was accompanied by the patient's
report that she was dizzy and that the sensation
duplicated the spells she had been having. The
response was much weaker on the second trial.
There were no other positions tested that pro-
voked the patient's symptoms ofdizziness . Based
on these observations, a diagnosis of benign
paroxysmal positioning vertigo was made, and
a maneuver to relieve the symptoms was per-
formed . Today, 7 months later, she reports peri-
odic slurring of her speech, but her position-
related vertigo has completely resolved .
The maneuver we used is called the canalith
repositioning procedure, first reported by Epley
in 1980 . A more refined procedure was de-
scribed by Epley (1992) as follows (Fig. 7) :
1 . The patient is seated on a table so that
when laid back, his/her head will extend
off the end 45 degrees toward the affected
ear. In this position, it is essential to wait
a minimum of 30 seconds for the delayed
response . (We have seen responses de-
layed as much as 40-50 seconds for some
patients .)
2. Following cessation of the nystagmus, the
head is rotated 90 degrees (45 degrees off
center, away from the affected ear). The
patient is kept in this position for a dura-
tion equaling the delay in the response
plus the duration of the nystagmus (T sec
= delay + duration).

CALORI C Riyht Ear/Wa :ra 2 0-Ma1-92 Id : 188 Figure 4A Normal results for
fixation suppression during
R20 ~ calorics .
R1 0
w J
0-
u
0
L10-

L20-
., . . . . . . . . . . 1:,53 , .
Number of beats : 67 SPU= -7 .6

80-

w 40-
N
W
0 0-

-40-
N

-80 ~
0ll02030405060708090100110120130140
RC= * ::*** LC= *a**a RW= ***** LW= 55 .8

387
Journal of the American Academy of Audiology/Volume 4, Number 6, November 1993

ZH1av-92 Id : 188 Figure 4B Normal results for

smooth ocular pursuit

. .- .- . . - MS-,J
e e9 500
Frequency= 8 .29 Hz R Gain= 8 .94 L Gain= 8 .9 9 Phase Shift= -9 .9 "

3. The patient's head and body are then ro-
tated 135 degrees from the supine position
(the patient rolls over onto the shoulder
opposite the affected ear), and that posi-
tion is maintained for another like time
period, i.e ., T sec .
4. Maintaining the same head position, the
patient is then raised slowly to a sitting
position and held there for T sec.
5. The patient's head is then turned forward
and down 20 degrees for T sec.
ing the head as erect as possible for 48 hours,
avoiding excessive head movements (especially
in the vertical plane), and not lying with the
affected side down for 9 days . Complete instruc-
tions are found in the Appendix . When these
instructions have been completed for the speci-
fied length of time, the patients are asked to
return to normal activities without movement
restrictions .
SUMMARY

The patients are asked to visually fixate in

each position . These five steps are repeated
until there is no nystagmus or subjective dizzi-
ness in any of the positions .
Written instructions are given to the pa-
tients and discussed with them after completing
the maneuver . These instructions include keep-
A patient having a classic history and
clinical findings for BPPV was reviewed .
Vestibular testing was bypassed initially in
favor of MRIs and led to neurosurgery for what
appeared to be a benign, congenital cerebellar
cyst . Further testing at our facility demon-
strated results consistent with classic BPPV.

2"ar-92 Id ; 188 Figure 4C Normal results for

saccadic eye movement testing.

N
W
W
K

WW
0

30 20 18 816-2 -
SACCADE AMPLITUDE (DEG)

z
W
u
W
a
a

Ki ntwara
.- . i Lefiw
1
30
J~_ 20 10-B'r 10 20 30
SACCADE AMPLITUDE (DEG)

388
 Benign Paroxysmal Positioning Vertigo/Lynn and Brey

POSITIOHAL~Supine/EC Z"ar-92 Id: 188 Figure 5A Recording demon-

-1 strating right-beating positional
nystagmus obtained with eyes
closed and alerting in the supine
position .

Number of beats : 22 SPII= -4 .6

0102030405860788690100110 28-1
1=1 6
SPU= -4

Figure 5B Recording demon-

POSITI OHAL~HeaA Lt/EC a:-9 Id. 188 strating right-beating positional
R20- nystagmus obtained with eyes
closed and alerting in the head-
R10- left position .
N
W
W
0-
W
0
L10-

L2e-
.. ... . . . . .. . .
Number of beats : 26 SPU= -3 .6

20

W 10
N

W 0

a -l0
N

-20
01020204e206070809010011012013r'71_4 6
SPU= -3

IYIf.9~/IILfl1BI~Ti ":AStrSIStt/I~ll Z"aT-92 Id : 188 Figure 5C Recording demon-

strating right-beating positional
nystagmus obtained with eyes
closed and alerting in the head-
hanging position .

Numbe r of beats : 16 SPU= -4.4

Slo w Ph ase U e l oc ir v

0110263040506B7Be09BfaAIt o12'n~t'a da
SPU= -5

389
 Journal of the American Academy of Audiology/Volume 4, Number 6, November 1993
MOTOR CONTROL TEST
=or
= o.: .,
Weight Symmetry Weight Symmetry
Adaptation - Toes Up Adaptation - Toes Down
zm
0 0 0
Eart.ns- .-c.naQN*,aa, -- ti~.VUn ...rv.n
- ~,ES:--Dr R- zo- sar - .- . .u
Figure 6 Computerized dynamic posturography test results for the motor and sensory conditions.
Positional vertigo was satisfactorily resolved
with a canalith repositioning procedure . This
observation implies an unlikely relationship
between the patient's symptoms and the cer-
ebellar lesion . This case illuminates the impor-
tance of ENG with Dix-Hallpike testing. It
should be emphasized that the treatment proce-
dures described here should be applied only
after the presence of BPPV has been confirmed.
This particular form of patient management
should not preclude comprehensive medical as-
sessment to rule out any coexisting, treatable
pathology.
REFERENCES
Baloh R, Honrubia V, Jacobson K. (1987) . Benign
positional vertigo: clinical and oculographic features in
240 cases . Neurology 37 :371-378 .
Baloh R, Sakala S, Honrubia V. (1979a). Benign paroxys-
mal positional nystagmus. Am J Otolaryngol 1:1-6 .
Baloh R, Sakala S, Honrubia V. (1979b). The mechanism
of benign paroxysmal positional nystagmus. Adv
Otorhinolaryngol 25 :161-166 .
Barany R . (1921) . Diagnose von Krankheitserscheinun-
gen im Bereiche des Otolithenapparates . Acta Otolaryngol
(Stockh) 2 :434-437 .
Barber H. (1984) . Positional nystagmus. Otolaryngol
Head Neck Surg 92 :649-655 .
390
EOUITEST SUMMARY
mw°a~eor
-av: wuw.Q;
.se s..r++a..-°wn.,.m or .: w. m, .~
Equilibrium Score
Sensory Analysis Strategy Analysis COG Alignment
r r
i
° soM ~s
Dix M, Hallpike C . (1952) . The pathology, symptoma-
tology and diagnosis of certain common disorders of the
vestibular system . Proc R Soc Med 45 :341-354 .
Drachman D, Hart C . (1972). An approach to the dizzy
patient . Neurology 22 :323-334 .
Epley J. (1980) . New dimensions of benign paroxysmal
positional vertigo . Otolaryngol Head Neck Surg 88 :
599-605.
Epley J. (1992). The canalith repositioning procedure: for
treatment of benign paroxysmal positional vertigo.
Otolaryngol Head Neck Surg 107:399-404.
Fernandez C, Alzate R, Lindsay J. (1959) . Experimental
observations on postural nystagmus in the cat. Ann Otol
Rhinol Laryngol 68:816-829 .
Herndon J, Haug 0, Horowitz M, Lynes T. (1975). Benign
paroxysmal positional vertigo : a clinical study. Ann Otol
Rhinol Laryngol 84:218-222 .
Katsarkas A, Kirkham T. (1978). Paroxysmal positional
vertigo: a study of 255 cases. J Otolaryngol 7:320-330.
Mohr D. (1986) . The syndrome of paroxysmal positional
vertigo: a review . West J Med 145 :245-250 .
Parnes L, McClure J. (1991) . Free-floating Endolymph
Particles: A New Operative Finding During Posterior
Canal Occlusion . Paper presented at the Meeting of the
Eastern Section of the American Laryngological,
Rhinological, and Otological Society, February, Philadel-
phia, PA .
Stable J, Terins J. (1965) . Paroxysmal positional
nystagmus : an electronystagmographic and clinical study.
Ann Otol Rhinol Laryngol 74 :69-83 .
 Benign Paroxysmal Positioning Vertigo/Lynn and Brey

Figure 7 "Positions for the canalith repositioning procedure (CRP), targeting left
posterior semicircular canal (PSC). Dark figure, side view ; boxes, operator's exposed
view of left labyrinth, showing gravitating canaliths. Semicircular canals are
labeled. S (Start), patient is seated, operator behind, oscillator(') applied. 1, Head is
placed over the end of the table, 45 degrees to the left (canaliths gravitate to center
of PSC) . 2, While head is kept tilted downward, it is rotated to 45 degrees right
(canaliths reach common crus). 3, Head and body are rotated until facing downward
135 degrees from supine position (cannaliths traverse common crus). 4, While head
is kept turned right, patient is brought to sitting position (canaliths enter utricle).
5, Head is turned forward, chin down 20 degrees. General: Pause at each position
until induced nystagmus approaches termination, or T s (delay + duration) if no
nystagmus. Keep repeating entire series (1 through 5) until no nystagmus any
position pg. 401 ." (Reprinted from Epley J. [1992] . The canalith repositioning
procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head
Neck Surg 107:401-404 . With permission from Dr. John Epley and Otolaryngology-
Head and Neck Surgery.)
'Note: Oscillator was not used while carrying out maneuver for patient reviewed.

APPENDIX

Patient instructions for the Epley Maneuver :

1. For the next 2 days and nights (48 hours),
you should keep your head completely ver-
tical. To sleep, you might sit in a recliner
chair, but do not lie all the way back; just far
enough to support your head. You might
devise a support for your head by purchas-
ing a neck brace or by pinning two pillows
next to your head .
2. Next, please avoid any head movements
upward or downward for the next week and
try to move your head and body as a unit
without excessive turning of your neck.
3 . Do not sleep on the side that generates your
dizziness for an additional week . You might
pin a pillow to that shoulder to keep you
from rolling over on it during the night. For
example : if your right ear down is causing
the problem, then sleep on your left side or
stomach.