Benign paroxysmal positional vertigo: Difference between revisions
 
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==Background==
==Background==
[[File:Balance Disorder Illustration A.png|thumb|Exterior of labyrinth of the inner ear.]]
*Abbreviation: BPPV
*Due to canalolithiasis (migration of otoconia into one of the semicircular canals)  
*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 age is mid-50s; women are twice as likely to be affected as men
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==Clinical Features==
==Clinical Features==
*Sudden-onset vertigo and associated nystagmus precipitated by head movements
*Sudden-onset [[vertigo]] and associated [[nystagmus]] precipitated by head movements
**Latency period <30s between provocative head position and onset of nystagmus
**Latency period <30s between provocative head position and onset of nystagmus
**Intensity of nystagmus increases to a peak before slowly resolving
**Intensity of nystagmus increases to a peak before slowly resolving
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*[[Nausea/vomiting]] common
*[[Nausea/vomiting]] common
*Symptoms worse in the morning (symptoms fatigue as day goes on)
*Symptoms worse in the morning (symptoms fatigue as day goes on)
*No associated hearing loss or tinnitus
*No associated [[hearing loss]] or [[tinnitus]]
*MUST distinguish from central vertigo ([[Vertigo#HINTS Exam|HINTS Exam]], [[Cerebellar stroke]])


==DDX==
==Differential Diagnosis==
See [[Vertigo|Vertigo#DDX]]
{{Vertigo DDX}}


==Diagnosis==
==Evaluation==
*Dix-Hallpike Maneuver (50-80% Sn)
''See [[vertigo]] for a general approach''
**Contraindications:
***Carotid bruits
***Cerebrovascular disease
***Concern for vertebrobasilar insufficiency
***Spinal injury
***Cervical spondylosis
**Procedure
***Step 1 of the Epley maneuver (see below)
***Positive test = onset of nystagumus after few seconds of latency and lasting <30s
***If pt has positive test with head turned to right then right ear is affected


==Treatment==
===Dix-Hallpike Maneuver===
*Epley 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>''
**Dix-Hallpike maneuver plus additional maneuvers to replace the migrated otolith
*Do not attempt provocative maneuvers if the patient is symptomatic with nystagmus at rest
**Each step should be done slowly (about 30s)
====Procedure====
**May require multiple attempts; pt can perform on own at home
*Patient sits upright
*Meds
*Patient's head is rotated to one side by 45 degrees. Then quickly lie the patient down
**Scopolamine transdermal patch 0.5mg (behind ear) QID
*Maintain the head in 45 degree rotation but also 20 degrees of extension off the end of the table.
**Diphenhydramine (benadryl) 25-50mg IM, IV, or PO q4hr or meclizine 25mg PO QID
*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==
==Disposition==
*Refer pts w/ persistent symptoms to an ENT
*Consider referral to ENT for persistent symptoms despite treatment
 
==Epley Maneuver==
[[File:Epley.jpg]]


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


==Source==
==External Links==
*UpToDate
*[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:ENT]]
[[Category:Neuro]]
[[Category:Neurology]]

Latest revision as of 23:10, 4 January 2023

Background

Exterior of labyrinth of the inner ear.
  • 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 (HINTS Exam, Cerebellar stroke)

Differential Diagnosis

Vertigo

Evaluation

See vertigo for a general approach

Dix-Hallpike Maneuver

  • 50-85% Sensitive for BPPV[1]
  • 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[2]

Management

Epley Maneuver[3]

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%[4]

Medical management

Disposition

  • Consider referral to ENT for persistent symptoms despite treatment

See Also

External Links

References

  1. ↑ Sacco RR et al. Management of Benign Paroxysmal Posi- tional Vertigo: A Randomized Controlled Trial. J Emerg Med. 2014 Apr;46(4):575-81
  2. ↑ 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.
  3. ↑ 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
  4. ↑ 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.
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