Benign Paroxysmal

Positional Vertigo
B.P.P.V.
Dr. Abdulrahman Hagr MBBS FRCS(c)
Assistant Professor King Saud University
Otolaryngology Consultant
Otologist, Neurotologist & Skull Base Surgeon
King Abdulaziz Hospital
 Benign paroxysmal
positional vertigo
History
Pathology
Management
History
P/E
Treatment
Benign Paroxysmal Positional Vertigo

1921 first described in by Brny

1952, Dix and Hallpike
reported this entity in a large group of
patients.
described the Dix-Hallpike maneuver
recognized features of the nystagmus
Latency
directional characteristics
brief duration
Reversibility
fatigability .
 BPPV
Schuknecht 1969 (Cupulolithiasis )
loose otoconia from the utricle
PSCC

McClure
1979 Canalithiasis mechanism
 Benign paroxysmal
positional vertigo
History
Pathology
Management
History
P/E
Treatment
 Incidence
30% of peripheral vestibular disease
15 per 100,000 in Japan
64 per 100,000 in Minnesota.
Twice Mnire's
mean age fifth decades
Increases with age.
Women:men 1.6:1
 Etiology
Primary or idiopathic (50%70%)
Secondary (30%50%)
Viral labyrinthitis (15%)
Head trauma (10%)
Mnires disease (5%)
Migraines (< 5%)
Inner ear surgery (< 1%)
BPPV: Pathophysiology
Degenerative debris from
utricle (otoconia)

Canalithiasis Theory
floating freely in the endolymph

Cupulolithiasis Theory
Adhering to the cupula
 ? PSCC
PSCC
Hangs down like the
water trap in a drain
pipe

Allowing the crystals to

settle in the bottom of
the canal.
 Benign paroxysmal
positional vertigo
History
Pathology
Management
History
P/E
Treatment
 History
Sudden
Seconds
Severe vertigo
Bouts of vertigo remissions
Chronic balance problems
Worse in the morning
 History
Associated with change in head position.
rolling over or getting into bed
assuming a supine position.
arising from a bending position
looking up to take an object off a shelf
tilting the head back to shave
turning rapidly.
 Benign paroxysmal
positional vertigo
History
Pathology
Management
History
P/E
Treatment
 Dix-Hallpike Maneuver
Hagr 6 D
1. Delay seconds latency
2. Downward (Geotropic)
3. Duration <1 minute
4. Directional change
5. Dizziness (Subjective)
6. Disappear fatigable
 Benign paroxysmal
positional vertigo
History
Pathology
Management
History
P/E
Diagnosis
Treatment
 Test Results
ENG limitation
Do not record the torsion
Low frequency(0.003 Hz)*
Lateral SCC
LOC

Rotational-chair & posturography have no role

Imaging with CT scanning or MRI is

unnecessary
 D/D
Postural hypotension
anti-hypertensive drugs
CV problems
Drugs
Cupula sensitive to gravity
PAN-1
PAN-2
Heavy water

Fistula
 D/D
History is virtually pathognomonic
Only type of vertigo
Multiple times per day
brief episodes
NO auditory complaints
No neurological
 Benign paroxysmal
positional vertigo
History
Pathology
History
P/E
Treatment
 Treatment
Patient education

Medical

Exercise

Surgical
 Patient education
Inner ear disease
Not CVA
Not Cancer
Recurrence
 Medical
Relieve of nausea
Promethazine
Prochlorperazine
 Epley Maneuver
Dr. John M. Epley 1980 *
Canalilith Repositioning
Canalith debris vestibule
single treatment = 95%
Remission

Otolaryngol Head Neck Surg 88:599605, 1980.

http://www.earinfosite.org/about.htm
 Epley Maneuver
Reclined head hanging 45 degree turn
 Epley Maneuver
Rotate 45 degrees contralateral
 Epley Maneuver
Head and body rotated to 135 degrees
from supine
 Epley Maneuver
Keep head turn and to sitting
Turn forward chin down 20 degrees
Video
Sleep semi-recumbent for the next two nights
 Brandt and Daroff exercises
Seated eyes closed
Tilted laterally to precipitating position
Lateral occiput resting
Vertigo subsides
Sit up for 30 sec
Opposite head down position 30 sec
Vertigo opposite (bilateral) maintain until
resolves
Every 3 hrs while awake, until 2 days free
Brandt-Daroff Exercises
 Surgical ?
Section of singular nerve

Canal occlusion

Vestibular nerve section

 Horizontal canal BPPV
17% of cases
Supine head lateral provocative
Cupulolithiasis > canalithiasis
From reposition of PSCC for BPPV
 Horizontal canal BPPV
Latency < 3 sec
< 1 min duration
may beat toward or away from side of the cupula
No fatigability
92% Side lying with the affected ear up for 12 h
resolves much more quickly than PSCC-BPPV
 Superior canal BPPV
Least common

Dix-Hallpike positioning testing

Rt PSCC = Lt SSCC vice versa
Thank
You
BPPV Results
 Bedside Evaluation
Static Vestibular Balance Nystagmus:
Check direction
Check for torsional component
Check for gaze suppression
 BPPV
Cawthorne 1954
1st exercises for vestibular disorder
Semont
Liberatory maneuver
1st rapid single treatment
83.96% one maneuver 92.68% two
4.22% recurrence
Others less success, too violent
Benign Paroxysmal Positional Vertigo

The most common peripheral vestibular disorder

semicircular canal becomes sensitive to gravity
Dix-Hallpike Maneuver
Brandt and Daroff