View source for Benign paroxysmal positional vertigo

==Background==
*Abbreviation: BPPV
*Due to canalolithiasis (migration of otoconia into one of the semicircular canals) 
*Mean age is mid-50s; women are twice as likely to be affected as men
*Mean duration is 2 weeks

==Clinical Features==
*Sudden-onset [[vertigo]] and associated [[nystagmus]] precipitated by head movements
**Latency period <30s between provocative head position and onset of nystagmus
**Intensity of nystagmus increases to a peak before slowly resolving
**Duration of vertigo and nystagmus ranges from 5–40s
**Repeated head positioning causes vertigo and nystagmus to fatigue and subside
**Nystagmus reverses direction during the head down and head up portions of Dix-Hallpike 
*[[Nausea/vomiting]] common
*Symptoms worse in the morning (symptoms fatigue as day goes on)
*No associated [[hearing loss]] or [[tinnitus]]
*MUST distinguish from central vertigo ([[Vertigo#HINTS Exam|HINTS Exam]], [[Cerebellar stroke]])

==Differential Diagnosis==
{{Vertigo DDX}}

==Evaluation==
''See [[vertigo]] for a general approach''

===Dix-Hallpike Maneuver===
*''50-85% Sensitive for BPPV<ref>Sacco RR et al. Management of Benign Paroxysmal Posi- tional Vertigo: A Randomized Controlled Trial. J Emerg Med. 2014 Apr;46(4):575-81</ref>''
*Do not attempt provocative maneuvers if the patient is symptomatic with nystagmus at rest
====Procedure====
*Patient sits upright
*Patient's head is rotated to one side by 45 degrees. Then quickly lie the patient down
*Maintain the head in 45 degree rotation but also 20 degrees of extension off the end of the table.
*Observe the eyes for 45 seconds for nystagmus.  There is often 15 seconds of latency prior to symptoms. 
**Immediate symptoms requires consideration for central etiology
*'''A positive test for BPPV is evidenced by the rotational (torsional) nystagmus
**Fast phase of the rotatory nystagmus is toward the affected ear (geotropic nystagmus), which is the ear closest to the ground
**Rotational nystagmus away from affected ear (ageotropic nystagmus) requires consideration for central lesion

====Contraindications<ref>Humphriss, Rachel; Baguley D; Sparks V; Peerman S; Mofat D (2003). "Contraindications to the Dix-Hallpike manoeuvre : a multidisciplinary review". International Journal of Audiology 42 (3): 166–173.</ref>====
*Concern for [[Cervical Artery Dissection]]
*[[CVA|Cerebrovascular disease]]
*Concern for [[vertebrobasilar insufficiency]], See [[Stroke syndromes]]
*Spinal injury
*Cervical spondylosis

==Management==
===Epley Maneuver<ref>Hilton, Malcolm P; Pinder, Darren K (2004). "The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo". In Hilton, Malcolm P. Cochrane Database of Systematic Reviews </ref>===
[[File:Epley.jpg|thumb|Epley manuver]]
*Epley begins after the last step of the Dix Hallpike
*Patient remains in the position with exacerbated nystagmus for approximately 1–2 minutes.
*Patient's head is then turned 90 degrees to the opposite direction so that the unaffected ear faces the ground
**Maintain the 20 degree neck extension
*Keep the head and neck in a fixed position while the patient rolls onto their opposite shoulder. The patient is now looking downwards at a 45 degree angle.
*Keep the patient in the new position for 1 minute.
*Finally bring the patient up to sitting while holding the head in 45 degree rotation.
*May require multiple attempts, but you can discharge patient home with daily exercises
**Improvement after x1 in 47% of patients, after x2 an additional 16%, and after x3 an additional 21%<ref>Hughes D, Shakir A, Goggins S, et al. How many Epley manoeuvres are required to treat benign paroxysmal positional vertigo? J Laryngol Otol. 2015; 129(5):421-424.</ref>

===Medical management===
*[[Antihistamines]]
**[[Diphenhydramine]] (Benadryl) 25-50mg IM/IV/PO q4hr
**[[Meclizine]](Antivert, Antrizine, Dramamine) 25mg PO QID
**[[Promethazine]](Phenergan, Anergan, Prorex) 12.5-25mg PO/IM/IV q4-6hr
*[[Anticholinergic]]
**[[Scopolamine]] transdermal patch 0.5mg (behind ear) QID
*[[Benzodiazepines]]
**[[Lorazepam]] (Ativan), [[diazepam]] (Valium) or Klonopin ([[clonazepam]])

==Disposition==
*Consider referral to ENT for persistent symptoms despite treatment

==See Also==
*[[Vertigo]]
*[[Dizziness]]
*[[Cerebellar Stroke]]
*[[Vertigo#HINTS Exam|HINTS Exam]]

==External Links==
*[http://www.youtube.com/watch?v=7ZgUx9G0uEs YouTube: How to do Epley Manuever]
*[http://www.youtube.com/watch?v=eOuzUi5ckrk Dix-Hallpike and Epley Maneuvers for BPPV, in Claymation]
*[http://www.dizziness-and-balance.com/disorders/bppv/home/home-pc.html Home Treatments of Benign paroxysmal positional vertigo]

==References==
<references/>
[[Category:ENT]]
[[Category:Neurology]]