Benign Paroxysmal Positional Vertigo
Benign Paroxysmal Positional Vertigo
Benign Paroxysmal Positional Vertigo
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<strong>Benign</strong> <strong>Paroxysmal</strong><br />
<strong>Positional</strong> <strong>Vertigo</strong><br />
GP Audiology Update Day<br />
Debbie Cane<br />
Senior Clinical Scientist, Audiology Department<br />
Debbie.Cane@royalberkshire.nhs.uk
BPPV: Overview<br />
Incidence and<br />
symptoms<br />
Testing<br />
Treatment<br />
Practical<br />
Electron microscope of otoconia<br />
David Lim
BPPV<br />
Caused by otoconia<br />
present within the<br />
semicircular canals<br />
Most common balance<br />
organ problem<br />
(20-40%)<br />
Increases in incidence<br />
with age
Presentation<br />
Sudden, intense vertigo and nausea<br />
Duration: 5-40 seconds<br />
After brief latency (usually)<br />
On head movements wrt gravity<br />
<br />
<br />
<br />
<br />
Lying down/getting out of bed<br />
Rolling in bed<br />
Looking up<br />
Bending down
Comparison with other Balance Organ<br />
Disorders
Causes<br />
<br />
<br />
<br />
<br />
BPPV<br />
49% Idiopathic<br />
18% Trauma<br />
18% with Menieres/VBI/MS<br />
15% with Vestibular neuritis<br />
Types<br />
• Canalithiasis (most)<br />
• Cupuloithasis<br />
Canal affected<br />
<br />
Posterior: 94%<br />
<br />
Horizontal: ~3-12%<br />
<br />
Anterior: ~2%
What would be your Ideal Test<br />
Quick<br />
Cheap<br />
Easy<br />
Test results immediate
Testing for BPPV<br />
What you need<br />
<br />
<br />
<br />
One couch (should already have)<br />
One confident GP (you after today!)<br />
One compliant patient (not always so easy)<br />
Total test time: 4 minutes<br />
<br />
<br />
2 minutes: to ensure no contraindications and show<br />
patients manoeuvre, help patient on couch<br />
1 minute per side for test<br />
Test result immediate<br />
<br />
If +ve refer to audiology, seen within 2-6 weeks,<br />
symptom free patient (in most) after this session
Dix Hallpike<br />
http://emcrit.org
Dix Hallpike-Barker BPPV CD rom
Right Dix Hallpike<br />
1. Sat upright with right torsion 45°<br />
2. Right head hanging position<br />
Furman, JM & Cass, SP, 1999
Absolute Contra Indications for Dix<br />
Hallpike: Humphriss 2003<br />
Severe cervical spine or lower back problems,<br />
injury or surgery eg RA, fracture, whiplash (see footnote)<br />
Carotid sinus syncope<br />
VBI proven and verified<br />
Vascular dissection syndrome<br />
Arnold Chiari malformation<br />
Footnote: Cervical spine instability including atlanto-axial subluxation, occipitoatlantal<br />
instability, prolapsed disc with radiculopathy, cervical myelopathy, , acute trauma to<br />
neck ‘whiplash’ restricting torsional movement, previous cervical spine surgery, recent<br />
fracture of cervical spine or fracture of odontoid peg aplasia of odontoid process,<br />
severe rheumatoid arthritis affecting neck
Functional Neck Mobility<br />
Assessment: Humphriss<br />
If patient can sit for 30 s without pain or<br />
discomfort with<br />
<br />
Neck torsion 45°: : side lying test √<br />
<br />
Neck torsion + extension: Dix Hallpike √<br />
Humphriss 2003
Other Points<br />
Instructions important, show the patient<br />
Observe eyes for positional nystagmus<br />
Start with least suspect ear<br />
Ask the patient to lie down<br />
Support patients head and neck from<br />
behind sat on chair to protect your back
Other Points (2)<br />
Hold position for 30-45 seconds<br />
Quickly down and slowly up<br />
Check for habituation- a repeat<br />
manoeuvre should give a lesser response
Modifications for the Elderly<br />
Possible in most<br />
Ensure no contraindications<br />
<br />
eg carotid sinus syncope, VBI, severe neck problems<br />
Ensure patient safety and use 2 clinicians<br />
<br />
<br />
<br />
Dix Hallpike-do testing slowly (to avoid postural<br />
hypotension)<br />
Modified supported DH with patients head flat on<br />
couch (Angeli et al RCT > 70 years)<br />
Sidelying test
Positive Dix Hallpike<br />
Nystagmus for posterior canal canalithiasis<br />
<br />
<br />
<br />
<br />
<br />
Torsional to undermost ear + upbeating<br />
Latency: 10-30 sec, duration d<br />
10-45 seconds<br />
May reverse in direction on rising<br />
Habituation of response with repeat manoeuvre<br />
Subjective report of vertigo by patient<br />
<br />
<br />
(Anterior: torsional and downbeating on DH)<br />
(Horizontal: horizontal on roll test)
Shepherd
Left Posterior Canal Canalithiasis
Quiz Time!<br />
Barker BPPV 2010
Barker BPPV 2010
Barker BPPV CD rom
Answers<br />
1. Torsional to left ear and upbeating<br />
2. Torsional to right ear and upbeating<br />
3. Horizontal (to the left)!
Side Lying Test<br />
When patient is unable to perform neck<br />
extension but is able to lie on their side<br />
BPPV pamphlet Herdman
Is it BPPV<br />
History very important<br />
Can get BPPV in absence of nystagmus<br />
but with vertigo in DH<br />
Good history, DH –ve and no vertigo<br />
reported<br />
<br />
<br />
Few otoconia which disperse during day- test<br />
in morning, get patient to keep diary<br />
Resolved: 1/3 of BPPV resolve in 3/52 (White)
Differential Diagnoses<br />
Central positional vertigo +/- nystagmus<br />
Non BPPV positional/ing vertigo<br />
<br />
<br />
With nystagmus<br />
• Perilymph Fistula<br />
• Superior semicircular canal dehiescence<br />
• Labyrinthine hypofunction<br />
Without nystagmus<br />
• Orthostatic hypotension<br />
• Extreme neck movement/pathology
Management:<br />
Epley manoeuvre<br />
Furman, JM & Cass, SP, 1999
Dix Hallpike-Barker BPPV CD rom
Progression of Otoliths through Posterior Canal<br />
with Epley<br />
Step 1.<br />
Posterior<br />
Canal<br />
Vertical<br />
Step 2.<br />
Posterior<br />
Canal<br />
Horizontal<br />
Step 3.<br />
Posterior<br />
Canal<br />
Rotated<br />
Step 4.<br />
Posterior<br />
Canal<br />
Returned<br />
to Vertical
Summary<br />
BPPV is quick easy and cheap to<br />
diagnose- SO GO ON !<br />
If you dont feel able to test/treat-this is<br />
fine- check for red flags and refer to<br />
audiology balance clinic<br />
If you need further advise on how to test or<br />
treat, or on your diagnosis phone Debbie<br />
on 01183227143
Practical Demonstration of<br />
Dix Hallpike and Epley<br />
Please can I have a guinea pig!