Benign paroxysmal positional vertigo: Difference between revisions
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*MUST distinguish from central vertigo. See [[Vertigo#HINTS Exam|HINTS Exam]], See [[Stroke syndromes]], See [[Cerebellar stroke]]
*MUST distinguish from central vertigo. See [[Vertigo#HINTS Exam|HINTS Exam]], See [[Stroke syndromes]], See [[Cerebellar stroke]]


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


==Diagnosis==
==Diagnosis==

Revision as of 22:27, 1 March 2015

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
  • MUST distinguish from central vertigo. See HINTS Exam, See Stroke syndromes, See Cerebellar stroke

Differential Diagnosis

Vertigo

Diagnosis

Dix-Hallpike Maneuver

Procedure

  1. Patient sits upright
  2. Patient's head is rotated to one side by 45 degrees. Then quickly lie the patient down
  3. Maintain the head in 45 degree rotation but also 20 degrees of extension off the end of the table.
  4. Observe the eyes for 45 seconds for nystagmus. There is often 15 seconds of latency prior to symptoms.
  5. A positive test for BPPV is evidenced by the rotational nystagmus
    1. fast phase of the rotatory nystagmus is toward the affected ear, which is the ear closest to the ground


Epley Maneuver[3]

  1. The Epley begins after the last step of the Dix Hallpike
  2. The patient remains in the position with exacerbated nystagmus for approximately 1–2 minutes.
  3. The patient's head is then turned 90 degrees to the opposite direction so that the unaffected ear faces the ground
    1. Maintain the 20 degree neck extension
  4. 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.
  5. Keep the patient in the new position for 1 minute.
  6. Finally bring the patient up to sitting while holding the head in 45 degree rotation.
  • Repeat the Epley up to 3 times

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

Epley.jpg

Disposition

  • Refer pts w/ persistent symptoms to ENT

See Also

Source

  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
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