Benign paroxysmal positional vertigo

Background

• 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

DDX

See Vertigo

Diagnosis

• Dix-Hallpike Maneuver (50-80% Sn)
  • 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

• Epley maneuver:
  • Dix-Hallpike maneuver plus additional maneuvers to replace the migrated otolith
  • Each step should be done slowly (about 30s)
  • May require multiple attempts, but you can d/c pt home with daily exercises
  • See link below for YouTube How-To videos
• 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)

Epley Maneuver

Disposition

• Refer pts w/ persistent symptoms to ENT

See Also

• Vertigo
• Dizziness

Source

• UpToDate
• How to do Epley Manuever: http://www.youtube.com/watch?v=7ZgUx9G0uEs
• Dix-Hallpike and Epley Maneuvers for BPPV, in Claymation: http://www.youtube.com/watch?v=eOuzUi5ckrk