Benign Paroxysmal Positional Vertigo

Benign Paroxysmal
Positional Vertigo
GP Audiology Update Day
Debbie Cane
Senior Clinical Scientist, Audiology Department
Debbie.Cane@royalberkshire.nhs.uk

BPPV: Overview
Incidence and
symptoms
Testing
Treatment
Practical
Electron microscope of otoconia
David Lim

BPPV
Caused by otoconia
present within the
semicircular canals
Most common balance
organ problem
(20-40%)
Increases in incidence
with age

Presentation
Sudden, intense vertigo and nausea
Duration: 5-40 seconds
After brief latency (usually)
On head movements wrt gravity
Lying down/getting out of bed
Rolling in bed
Looking up
Bending down

Comparison with other Balance Organ
Disorders

Causes
BPPV
49% Idiopathic
18% Trauma
18% with Menieres/VBI/MS
15% with Vestibular neuritis
Types
• Canalithiasis (most)
• Cupuloithasis
Canal affected
Posterior: 94%
Horizontal: ~3-12%
Anterior: ~2%

What would be your Ideal Test
Quick
Cheap
Easy
Test results immediate

Testing for BPPV
What you need
One couch (should already have)
One confident GP (you after today!)
One compliant patient (not always so easy)
Total test time: 4 minutes
2 minutes: to ensure no contraindications and show
patients manoeuvre, help patient on couch
1 minute per side for test
Test result immediate
If +ve refer to audiology, seen within 2-6 weeks,
symptom free patient (in most) after this session

Dix Hallpike
http://emcrit.org

Dix Hallpike-Barker BPPV CD rom

Right Dix Hallpike
1. Sat upright with right torsion 45°
2. Right head hanging position
Furman, JM & Cass, SP, 1999

Absolute Contra Indications for Dix
Hallpike: Humphriss 2003
Severe cervical spine or lower back problems,
injury or surgery eg RA, fracture, whiplash (see footnote)
Carotid sinus syncope
VBI proven and verified
Vascular dissection syndrome
Arnold Chiari malformation
Footnote: Cervical spine instability including atlanto-axial subluxation, occipitoatlantal
instability, prolapsed disc with radiculopathy, cervical myelopathy, , acute trauma to
neck ‘whiplash’ restricting torsional movement, previous cervical spine surgery, recent
fracture of cervical spine or fracture of odontoid peg aplasia of odontoid process,
severe rheumatoid arthritis affecting neck

Functional Neck Mobility
Assessment: Humphriss
If patient can sit for 30 s without pain or
discomfort with
Neck torsion 45°: : side lying test √
Neck torsion + extension: Dix Hallpike √
Humphriss 2003

Other Points
Instructions important, show the patient
Observe eyes for positional nystagmus
Start with least suspect ear
Ask the patient to lie down
Support patients head and neck from
behind sat on chair to protect your back

Other Points (2)
Hold position for 30-45 seconds
Quickly down and slowly up
Check for habituation- a repeat
manoeuvre should give a lesser response

Modifications for the Elderly
Possible in most
Ensure no contraindications
eg carotid sinus syncope, VBI, severe neck problems
Ensure patient safety and use 2 clinicians
Dix Hallpike-do testing slowly (to avoid postural
hypotension)
Modified supported DH with patients head flat on
couch (Angeli et al RCT > 70 years)
Sidelying test

Positive Dix Hallpike
Nystagmus for posterior canal canalithiasis
Torsional to undermost ear + upbeating
Latency: 10-30 sec, duration d
10-45 seconds
May reverse in direction on rising
Habituation of response with repeat manoeuvre
Subjective report of vertigo by patient
(Anterior: torsional and downbeating on DH)
(Horizontal: horizontal on roll test)

Shepherd

Left Posterior Canal Canalithiasis

Quiz Time!
Barker BPPV 2010

Barker BPPV 2010

Barker BPPV CD rom

Answers
1. Torsional to left ear and upbeating
2. Torsional to right ear and upbeating
3. Horizontal (to the left)!

Side Lying Test
When patient is unable to perform neck
extension but is able to lie on their side
BPPV pamphlet Herdman

Is it BPPV
History very important
Can get BPPV in absence of nystagmus
but with vertigo in DH
Good history, DH –ve and no vertigo
reported
Few otoconia which disperse during day- test
in morning, get patient to keep diary
Resolved: 1/3 of BPPV resolve in 3/52 (White)

Differential Diagnoses
Central positional vertigo +/- nystagmus
Non BPPV positional/ing vertigo
With nystagmus
• Perilymph Fistula
• Superior semicircular canal dehiescence
• Labyrinthine hypofunction
Without nystagmus
• Orthostatic hypotension
• Extreme neck movement/pathology

Management:
Epley manoeuvre
Furman, JM & Cass, SP, 1999

Dix Hallpike-Barker BPPV CD rom

Progression of Otoliths through Posterior Canal
with Epley
Step 1.
Posterior
Canal
Vertical
Step 2.
Posterior
Canal
Horizontal
Step 3.
Posterior
Canal
Rotated
Step 4.
Posterior
Canal
Returned
to Vertical

Summary
BPPV is quick easy and cheap to
diagnose- SO GO ON !
If you dont feel able to test/treat-this is
fine- check for red flags and refer to
audiology balance clinic
If you need further advise on how to test or
treat, or on your diagnosis phone Debbie
on 01183227143

Practical Demonstration of
Dix Hallpike and Epley
Please can I have a guinea pig!