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Benign ParoxismalPositional Vertigo

(BPPV)PRITA & NOVA

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A 58 year old woman Occurrance of sudden vertigo and imbalance wit nausea

and vomiting !egan tat te morning wen se got out of bed"

Vertigo lasted less tan a minute but recurred wen se laybac# down in bed$ rolled over in bed$ or got u% again Re%orts no tinitus or earing loss ow sould tis %atient be evaluated and treated'

Case

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!PPV by far te most common causes ofvertigo$ is caracteri(ed by brief s%iningsensations$ wic are ty%ically induced bycange in ead %osition wit res%ect togravity

Re%orted %revalence between )*$+ and ,-$*cases %er )**$*** %o%ulation"

Preface

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 Te %revalence of idio%atic !PPV isincreased among elderely %ersons and

among women$ wit %ea# onset between5*.,* years of age and a female to maleratio of /0) to 10)

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 Te fundamental %ato2siological %rocessin !PPV in involves dislodged otoconia fromte macula of te utricular otolit tat enterte semicircular canal"

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!PPV sometimes involves multi%le canals$ma#ing it di3cult to identify te %atterns ofnystagmus and coose te best treatment

Pisycal e4amination reveals %ositionalnystagmus in more tan +* of %atientswit !PPV" Tis 2nding is elicated by%erforming s%eci2c maneuvers$ de%ending

on wic canal is a6ected

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!PPV involving te %osterior canal 7temost common ty%e is diagnosed on tebasis of nistagmus beating in an u%ward

and torsional direction$ wit te to% %olesof te eyes beating toward te lower ear$as observed wen te %atient is lying onone side during te 9i4.all%i#e

maneuver"

Posterior canalissemisircularis

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!PPV involving te ori(ontal canal iscaracteri(ed by nistagmus tat is eitergeotro%ic 7beating toward te ground or

a%ogeotro%ic 7beating toward te ceilingwen te ead is turned to eiter sidewile te %atient is in a su%ine %osition"

Horizontal canalis semisircularis

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!PPV involving te anterior canal ise4tremly rare$ and its %ato%ysiology is%oorly understood" Its allmar# is a

%ositional downbeat nystagmus wit atorsional nystagmus in wic te to% %olesof te eyes beat toward te involved ear"Patients wit tis ty%e of nystamus sould

be evaluated for central lesions altougsuc lesions are rarely found

Anterior canalissemisircularis

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!PPV ty%icallly resolves witout treatment" :%ontaneous resolusition in untreated %atients

was + days wen te ori(ontal canal wasa6ected and )+ days wen te %osterior canal

was a6ected " owever$ canalit.re%ositioning maneuvers can

be used to treat !PPV %rom%tly and e6ectively" ;edications are %rimarily used to relieve severe

nausea or vomiting"

Treatment

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 Te %attern of nystagmus during s maneuver el%sto %redict te success of treatment" @en te ead isturned ?* degrees away from te a6ected side 7afterbeing %laced in te initial 9i4.all%i#e %osition$te%ositioning nystagmus occasionally rea%%ears"According

to one re%ort$all ?? %atients wose nystagmusrea%%eared in te same direction as te originalnystagmus ad resolution after one or two a%%lications ofs maneuver$wereas only 1 of te )5 %atientswose nystagmus sifted to te o%%osite direction were

cured"owever$even in %atients wit nystagmus in teo%%osite direction$enoug debris may be removed fromte %osterior canal to relieve sym%toms"

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 Te semont maneuver can also be used to treat !PPVinvolving te %osterior canal"

 Tis maneuver can be used in lieu of s maneuver in%atients wo ave di3culties e4tending te

!ot s and :emont>s maneuvers may be re%eated

several times until no nystagmus is elicited" Patients wo reuire multi%le treatments can be instructed to

%erform te maneuvers at ome" In a randomi(ed$ controlled trial$ te success rate was ?5

wit self administration of s>s maneuver and 58 wit

self administration of :emont>s maneuver" :elf administered canalit re%ositioning maneuvers may be

more e6ective wen combined wit guided canalitre%ositioning maneuvers %erformed at a clinic"

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Nausea or vomiting and vertigo may occurduring tese maneuvers$and many %atientsave a sensation of being o6 balance andtransient di((iness wit ead motion forseveral days or more$even after succesfultreatment"

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 Tere are two ty%es of !PPV involving teori(ontal canal one in wic tenystagmus is geotro%ic and one in wic itis a%ogeotro%ic"Te former is commonlytreated wit te barbecue rotation"Itconsists of seuential ?* degree rotations ofte ead$2rst toward te a6ected ear andten toward te una6ected ear.

Horizontal canal

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@it tis maneuver$te otoconial debris migrates andeventually e4its te ori(ontal canal and %asses into tevestibule"

 Tis treatment is %referred for %atients wit severe$sym%tomstat worsen wit seuential canges in %osition and for tose

in wom it is unclear wic ear is a6ected"If lying on one sidefor a %rolonged %eriod is ine6ective$ te %atient can try lyingon te oter side for )/ ours"An alternative traetment isBufoni>s maneuver$in wic te %atient uic#ly lies down onte side of te una6ected ear and remains in tis %osition for) to / minutes$until te evo#ed nystagmus subsides"Te eadis ten uic#ly rotated -5 degrees toward te =oor and #e%t

in tis %osition for anoter / minutes$ after wic te %atientresumes an u%rigt %osition"

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!PPV involving te ori(ontal canal wit a%ogeotro%icnystagmus is attributed to otolitic debris tat isattaced to te cu%ula 7cu%ulolitiasis or tat is free.=oating witin te anterior arm of te ori(ontalsemicircular canal near te cu%ula7canalolitiasis"Treatment involves maneuversdesigned to detac te otolitic debris from te cu%ulaor to move te debris from te anterior arm of teori(ontal canal to te %osterior arm 7Table /" Possible

adCunctive strategies for tis ty%e of !PPV includeead.sa#ing in te ori(ontal %lane for )5 second andmodi2ed version of semont>s maneuver and Bufoni>smaneuver"

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In Bufoni>s maneuver for !PPV involving teori(ontal canal wit a%ogeotro%icnystagmus$te %atient sits u%rigt$loo#ingstraigt ead$and ten uic#ly lies down on

te a6ected side and remains in tis %ositionfor ) to / minutes after te nystagmus assto%%ed or as been mar#edly reduced"Tente ead is uic#ly turned -5 degrees toward

te ceiling and is eld in tis %osition for /minutes$after wic te %atient slowlyresumes te sitting %osition"

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A randomi(ed trial sowed signi2cantlyiger rates of immediate resolution ofsym%toms wit te ead.sa#ing andBufoni>s maneuver 7,/ and

+1$res%ectively tan wit a sammaneuver 715Doutcomes wit tesemaneuvers 7u% to two re%etitions of eacmaneuver at te time of te initial treatment

remained su%erior to te outcome wit tesam maneuver at ) mont"

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Altoug randomi(ed trials ave com%ared tee6ectiveness of various maneuvers for s%eci2c ty%es of!PPV$it is not clear wic maneuver is te most e6ectivefor eac ty%e"It is also unclear wat strategy sould be%ursued if te initial maneuver is not e6ective":ould te

same maneuver be re%eated$or sould a di6erentmaneuver be %erformedDif te same maneuver isre%eated$ow many re%etitions sould be %erformed'Inaddition$te diagnostic criteria and re%ositioningmaneuvers for !PPV involving te anterior canal reuer

validation"Einally$altoug reduced vitamin 9 levels avebeen re%orted among %ersons wit !PPV as com%ared witcontrols$it is not #nown weter vitamin 9 su%%lementationreduces te ris# of incident or recurrent !PPV"

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Practice guidelines %ublised in /**8inde%endently by te American Academy ofNeurology and te American Academy ofOtolaryngology ead and Nec# :urgery

recommend only te use of s maneuver for!PPV involving te %osterior canal"Recommendations in tis article include otermaneuvers 7:emont>s maneuver for !PPVinvolving te %osterior canal and several otermaneuvers for !PPV of te ori(ontal canalDtese recommendations are based on data frommore recent randomi(ed trials"

GUIDEI!E"

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 Te %atient described in te vignette as vertigo and nystagmus%rovo#ed by a cange in ead %osition$witout oter sym%tomsor signs$2ndings tat are igly suggestive of !PPV" Patients wore%ort vertigo %rovo#ed by ead movements sould 2rstundergo te 9i4.all%i#e maneuver "Te develo%ment of briefvertigo associated wit %aro4ysmal u%beat and torsionalnystagmus is diagnostic of !PPV involving te %osterior canal7te most common ty%e of !PPV"Biven tis 2nding$werecommend te %erformance of s maneuver one or moretimes as needed in a given session$altoug :emont>s maneuverwould be a reasonable alternative"@e would e4%ect at least 8*

of %atients to be cured wit eiter maneuver at te 2rst visit"owever$te %atient sould be informed tat !PPV may recurand reuire retreatment"

 

C#!CU"I#!