Benign paroxysmal positional vertigo: Difference between revisions
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== | ==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) | |||
*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]] | |||
[[ | |||
[[Category: |
Latest revision as of 23:10, 4 January 2023
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 (HINTS Exam, Cerebellar stroke)
Differential Diagnosis
Vertigo
- Vestibular/otologic
- Benign paroxysmal positional vertigo (BPPV)
- Traumatic (following head injury)
- Infection
- Ménière's disease
- Ear foreign body
- Otic barotrauma
- Otosclerosis
- Neurologic
- Cerebellar stroke
- Vertebrobasilar insufficiency
- Lateral Wallenberg syndrome
- Anterior inferior cerebellar artery syndrome
- Neoplastic: cerebellopontine angle tumors
- Basal ganglion diseases
- Vertebral Artery Dissection
- Multiple sclerosis
- Infections: neurosyphilis, tuberculosis
- Epilepsy
- Migraine (basilar)
- Other
- Hematologic: anemia, polycythemia, hyperviscosity syndrome
- Toxic
- Chronic renal failure
- Metabolic
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]
- Concern for Cervical Artery Dissection
- Cerebrovascular disease
- Concern for vertebrobasilar insufficiency, See Stroke syndromes
- Spinal injury
- Cervical spondylosis
Management
Epley Maneuver[3]
- 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
- 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
External Links
- YouTube: How to do Epley Manuever
- Dix-Hallpike and Epley Maneuvers for BPPV, in Claymation
- Home Treatments of Benign paroxysmal positional vertigo
References
- ↑ Sacco RR et al. Management of Benign Paroxysmal Posi- tional Vertigo: A Randomized Controlled Trial. J Emerg Med. 2014 Apr;46(4):575-81
- ↑ 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.
- ↑ 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
- ↑ 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.