BPPV

Benign Paroxysmal Positional Vertigo

(BPPV)
•
• Benign: not a very serious or progressive
condition
• Paroxysmal: sudden and unpredictable in onset
• Positional: comes with a change in head position
• Vertigo: causing a sense of dizziness
Etiologi
• Idiopathic – 48%
• Head trauma
• Viral neuronitis
• Middle ear infection
• Surgical damage to the labyrinth
• Prolonged bed rest
PATHOPHYSIOLOGY OF BPPV
• Vertigo originates in Posterior Semi
circular canal in majority of cases
• Rarely in Lateral Semi circular Canal
and still rarer in Superior semi circular
Canal
• “Cupulolithiasis” – Schucknect
• “Canalithiasis” –Hal, Ruby, McClure,
Parnes, Epley
• Free Floating particles in endolymph of
Posterior Semi circular Canal
Theories of BPPV

1. Cupulolithiasis

• In 1962, Dr Harold Schuknecht proposed the cupulolithiasis (heavy cupula)

theory.
• Discovered basophilic particles or densities that were adherent to the cupula.
• He postulated that the PSC was rendered sensitive to gravity by these
abnormal dense particles attached to, or impinging on, the cupula.
• This produces persistent nystagmus and also explains the dizziness when a
patient tilts the head backward.
• Cupulolithiasis – possible role in atypical BPPV
2. Canalolithiasis :
– Hall, Ruby and McClure – 1980
– Free floating deposits demonstrated in Endolymph of PSSC–Parnes, McClure-1991
• The most widely accepted theory of the pathophysiology of BPV
• Otoliths (calcium carbonate particles) are normally attached to a membrane inside the utricle and
saccule
• Otoliths may become displaced from the utricle to enter the posterior semicircular duct since this is
the most dependent of the 3 ducts
• Changing head position relative to gravity causes the free Otoliths to gravitate longitudinally
through the canal.
• The concurrent flow of endolymph stimulates the hair cells of the affected semicircular canal,
causing vertigo.
• Explains all features of typical nystagmus
Canalolithiasis
Symptoms

• Discrete episodes of vertigo induced by specific head motions of

duration less than 1 min.
• Single bouts clustered in time with remissions lasting months or
more.
• Dizziness with rapid head movements. (Cupulolithiasis)
• Disequilibrium worse in the morning or after day time naps.
• Nausea and vomiting
NYSTAGMUS IN BPPV
• Nystagmus : characterization and types
– Rt / Lt , vertical / horizontal , changing
– Tortional = Rotational – clockwise / counterclockwise
– Geotropic- toward the earth
– Ageotropic – opposite
DIRECTION OF NYSTAGMUS

• Destructive lesion of the vestibular end organ or the vestibular nerve

will produce transient horizontal nystagmus with its quicker phase
towards the opposite side.
• Unilateral cerebellar lesion will produce vertigo with its quicker phase
to the same side
• Paretic lesion of labyrinth the nystagmus is towards healthy side
Diagnosis
1. Anamnesis
Pasien biasanya mengeluh vertigo dengan onset akut kurang dari 10-
20 detik akibat perubahan posisi kepala. Posisi yang memicu adalah
berbalik di tempat tidur pada posisi lateral, bangun dari tempat tidur,
melihat ke atas dan belakang, dan membungkuk. Vertigo bisa diikuti
dengan mual.
2. Pemeriksaan fisik
Pasien memiliki pendengaran yang normal, tidak ada nistagmus
spontan, dan pada evaluasi neurologis normal. Pemeriksaan fisik
standar untuk BPPV adalah : Dix-Hallpike
• Dix-Hallpike Tets
Tes ini tidak boleh dilakukan pada pasien yang memiliki masalah
dengan leher dan punggung. Tujuannya adalah untuk memprovokasi
serangan vertigo dan untuk melihat adanya nistagmus. Cara melakukannya
sebagai berikut :
BPPV - Treatment

• Watchful waiting
• Pharmacotherapy
• Canalith repositioning procedure
• Vestibular rehabilitation
• Surgery care
– Singular neurectomy
– Post. Canal occlusion
– Vestibular nerve section
Pharmacotherapy
• Directed principally at suppressing vestibular response.
• Alleviating nausea associated with vertigo.
• Does not treat underlying cause.
– Low dose diazepam – used prior to CRP
– Antiemetics like phenergan
– Longer acting vestibular suppressants like clonazepam for chronic
disequilibrium
Canalith Repositioning Procedure ( CRP )

• The treatment of choice for BPPV (Epley maneuver)

• The patient positioned in a series of steps so as to slowly move the
otoconia particles from the Posterior SCC into the utricle.
• Takes approximately 5 minutes.
• The patient is instructed to wear a neck brace for 24 hours and to not
bend down or lay flat for 24 hours after the procedure.
• Dix-Hallpike test is repeated soon after the CRP and after 1 week.
• If the patient does experience vertigo and nystagmus, then the CRP is
repeated with a vibrator placed on the skull in order to dislodge the
otoconia.
The Epley Maneuver
Manuver Semont
Brandt-Daroff exercise

• Method of treating BPPV, usually used when the office treatment

fails.
• These exercises should be performed
– For one week, three times per day
– For three weeks, twice per day.
• In each time, one performs the maneuver as shown five times.
• 1 repetition = maneuver done to each side in turn (takes 2 minutes)
Brandt-Daroff Exercises