Benign Paroxysmal Positioning Vertigo (BPPV) Tracy Murphy, Au.D

Benign ParoxysmalBenign ParoxysmalPositioning VertigoPositioning Vertigo

(BPPV)(BPPV)

Tracy Murphy, Au.D.Tracy Murphy, Au.D.

Role of the Audiologist in the Role of the Audiologist in the

diagnosis and treatment of the diagnosis and treatment of the

dizzy patientdizzy patient

PerspectivePerspective

Many disciplines address some functional Many disciplines address some functional aspects of balanceaspects of balance OtolaryngologyOtolaryngology Audiology Audiology NeurologyNeurology Cardiology Cardiology Physical / occupational therapy Physical / occupational therapy Ophthalmology Ophthalmology Psychology/PsychiatryPsychology/Psychiatry

No single discipline can No single discipline can claim exclusive control over claim exclusive control over

the domain of dizzinessthe domain of dizziness

Broad perspective – multidisciplinary Broad perspective – multidisciplinary approachapproach

Understand cause and effect relationships Understand cause and effect relationships as they pertain to dizziness and balanceas they pertain to dizziness and balance

Be more than a technician – 3 sources of Be more than a technician – 3 sources of knowledgeknowledge Patient experiencePatient experience Survey signs and symptomsSurvey signs and symptoms Knowledge of the disciplineKnowledge of the discipline

Diagnostic AcumenDiagnostic Acumen

All three knowledge sources are critical in All three knowledge sources are critical in order to come up with the correct order to come up with the correct diagnosisdiagnosis

Test data must be placed into the context Test data must be placed into the context of each specific case to determine its of each specific case to determine its significancesignificance

Audiologists have Audiologists have

so much to offer…so much to offer…

BPPVBPPV

IntroductionIntroduction

BPPV is a common cause of dizzinessBPPV is a common cause of dizziness BPPV is the most common cause of dizziness BPPV is the most common cause of dizziness

in the elderlyin the elderly Approximately 50% of people over the age of Approximately 50% of people over the age of

65 will experience BPPV65 will experience BPPV

Characterized by short episodes of Characterized by short episodes of dizziness associated with changes in head dizziness associated with changes in head positionposition

Anatomy OverviewAnatomy Overview

Copyright ©2003 CMA Media Inc. or its licensors

Parnes, L. S. et al. CMAJ 2003;169:681-693

Fig. 2: Osseous (grey/white) and membranous (lavender) labyrinth of the left inner ear


Semicircular CanalsSemicircular Canals

The vestibular labyrinth The vestibular labyrinth consists of three fluid-consists of three fluid-filled semicircular canals filled semicircular canals oriented at 90oriented at 90°° to each to each other, representing all other, representing all three planes of spacethree planes of space

Herdman & Tusa, 2004


Ampulla – dilated end of each canal that Ampulla – dilated end of each canal that houses a mound of hair cells called the houses a mound of hair cells called the cristae ampullariscristae ampullaris

The hair cells of the crista ampullaris The hair cells of the crista ampullaris project into the cupula, a gelatinous project into the cupula, a gelatinous structure that seals the semicircular canal structure that seals the semicircular canal and is displaced with angular acceleration and is displaced with angular acceleration of the headof the head


Angular head movements cause movement of the endolymph Angular head movements cause movement of the endolymph within the semicircular canals, placing pressure on the cupulawithin the semicircular canals, placing pressure on the cupula

Hair cells embedded in the cupula send excitatory or inhibitory Hair cells embedded in the cupula send excitatory or inhibitory signals depending on the direction of the fluid displacementsignals depending on the direction of the fluid displacement

Jacobson, et. al., 1997




Fig. 3: Schematic drawing of the physiology of the left posterior semicircular canal

Ampullopetal vs. ampullofugal displacementAmpullopetal vs. ampullofugal displacement


Utricle and SacculeUtricle and Saccule

Linear accelerometers oriented vertically Linear accelerometers oriented vertically (saccule) and horizontally (utricle) in the (saccule) and horizontally (utricle) in the vestibule of the labyrinthvestibule of the labyrinth

Hair cells are embedded in the maculae Hair cells are embedded in the maculae and covered with the otolithic membraneand covered with the otolithic membrane

Central Vestibular SystemCentral Vestibular System

Information from the hair cells in the Information from the hair cells in the semicircular canals is sent to the semicircular canals is sent to the vestibular nucleivestibular nuclei

Second order neurons transmit signals Second order neurons transmit signals through the medial longitudinal fasciculus through the medial longitudinal fasciculus to the third, fourth, and sixth oculomotor to the third, fourth, and sixth oculomotor nucleinuclei

Central Vestibular SystemCentral Vestibular System

Third order neurons Third order neurons innervate the extraocular innervate the extraocular musclesmuscles

The muscles are The muscles are responsible for making responsible for making eye movements equal to eye movements equal to and opposite head and opposite head movementmovement

Basis for the Basis for the vestibuloocular reflex vestibuloocular reflex (VOR)(VOR)


Mechanisms underlying BPPVMechanisms underlying BPPV

Dislodged otoconia from the utricle settle Dislodged otoconia from the utricle settle in a semicircular canal causing in a semicircular canal causing overexcitability with angular head overexcitability with angular head movementsmovements

How do the otoconia become dislodged?How do the otoconia become dislodged?

Causes of BPPVCauses of BPPV

Primary or idiopathic BPPVPrimary or idiopathic BPPV

Head traumaHead trauma

Vestibular neuritisVestibular neuritis

Viral labyrinthitisViral labyrinthitis

History of inner ear pathologyHistory of inner ear pathology

History of otologic surgeryHistory of otologic surgery

MigrainesMigraines

Mechanisms underlying BPPVMechanisms underlying BPPV



Fig. 4: Left inner ear

Canalithiasis vs. CupulolithiasisCanalithiasis vs. Cupulolithiasis

Mechanisms Mechanisms underlyingunderlying BPPV BPPV

CanalithiasisCanalithiasisDelayed onsetDelayed onset

Short durationShort duration

Symptoms coincide with nystagmusSymptoms coincide with nystagmus


Mechanisms Mechanisms underlyingunderlying BPPV BPPV

CupulolithiasisCupulolithiasis

Typically not delayed onsetTypically not delayed onsetLong durationLong duration

Symptoms may stopSymptoms may stop


Posterior Canal BPPVPosterior Canal BPPV

Characterized by brief attacks of rotary Characterized by brief attacks of rotary nystagmus caused by head movementsnystagmus caused by head movements Rolling over in bedRolling over in bed Looking up/downLooking up/down Bending forwardBending forward Sitting upSitting up Lying downLying down Turning quicklyTurning quickly


Most common variantMost common variant Position relative to vestibule Position relative to vestibule Canalithiasis more predominantCanalithiasis more predominant

Diagnosed using the Dix-Hallpike Diagnosed using the Dix-Hallpike ManeuverManeuver

Best seen with Frenzel lenses or Best seen with Frenzel lenses or VideonystagmographyVideonystagmography


Typically, the nystagmus beats toward the Typically, the nystagmus beats toward the undermost (affected) earundermost (affected) ear As seen by the investigatorAs seen by the investigator

Abnormal Dix-Hallpike maneuver to the Abnormal Dix-Hallpike maneuver to the rightright will will result in nystagmus with a counter-clockwise fast result in nystagmus with a counter-clockwise fast phasephase

Abnormal Dix-Hallpike maneuver to the Abnormal Dix-Hallpike maneuver to the leftleft will will result in nystagmus with a clockwise fast phaseresult in nystagmus with a clockwise fast phase


Diagnostic criteriaDiagnostic criteria

LatencyLatency

DurationDuration

Linear-rotary nystagmusLinear-rotary nystagmus

ReversalReversal

FatigabilityFatigability

Anterior Canal BPPVAnterior Canal BPPV

Least common variant – 1-2%Least common variant – 1-2%

Diagnosed using Dix-Hallpike ManeuverDiagnosed using Dix-Hallpike Maneuver

Characterized by downbeat rotary nystagmusCharacterized by downbeat rotary nystagmus Can be provoked from the opposite ear to the side of Can be provoked from the opposite ear to the side of

the Dix-Hallpike maneuverthe Dix-Hallpike maneuver Can be provoked from the Dix-Hallpike maneuver from Can be provoked from the Dix-Hallpike maneuver from

either side or head-hanging back positioneither side or head-hanging back positionDue to orientation of anterior limb of the anterior canal (near Due to orientation of anterior limb of the anterior canal (near saggital plane)saggital plane)

Will typically beat toward the affected earWill typically beat toward the affected ear

Horizontal Canal BPPVHorizontal Canal BPPV

Approximately 3-12% of individuals with Approximately 3-12% of individuals with paroxysmal positioning vertigoparoxysmal positioning vertigo

Diagnosed by positional test or Roll testDiagnosed by positional test or Roll test


Characterized by short latency horizontal Characterized by short latency horizontal nystagmus that is provoked by bilateral head nystagmus that is provoked by bilateral head turnsturns Prolonged duration and poor fatigabilityProlonged duration and poor fatigability

Nystagmus can be seen in both lateral right and Nystagmus can be seen in both lateral right and lateral left positionslateral left positions Geotropic nystagmus - “bad” ear typically has the Geotropic nystagmus - “bad” ear typically has the

strongest response strongest response Ageotropic nystagmus – “bad” ear typically has the Ageotropic nystagmus – “bad” ear typically has the

weaker response (inhibitory response)weaker response (inhibitory response)


Nystagmus can be geotropic or ageotropicNystagmus can be geotropic or ageotropic

Geotropic – canalithiasisGeotropic – canalithiasis Otoconia move freely in the canal to the Otoconia move freely in the canal to the

lowest position (toward the ampulla) causing lowest position (toward the ampulla) causing an excitatory response with the affected ear an excitatory response with the affected ear downdown


Ageotropic – cupulolithiasisAgeotropic – cupulolithiasis Otoconia are adherent to the cupula causing Otoconia are adherent to the cupula causing

gravity sensitivity and an inhibitory response gravity sensitivity and an inhibitory response with the affected ear downwith the affected ear down

Nystagmus will beat toward the uppermost Nystagmus will beat toward the uppermost earear

Herdman & Tusa, 2004Right Horizontal SCC

Mixed Canal BPPVMixed Canal BPPV

BPPV can affect more than one BPPV can affect more than one semicircular canal resulting in varying semicircular canal resulting in varying patterns of nystagmuspatterns of nystagmus

Posterior and horizontal canals most commonPosterior and horizontal canals most common Simultaneous posterior and horizontal canal Simultaneous posterior and horizontal canal

BPPVBPPV

CASE STUDIESCASE STUDIES

HBHB

41 year old female41 year old female

Three month hx of dizziness when tilting Three month hx of dizziness when tilting head to the righthead to the right

Dizziness Dizziness lasts approximately 5 seconds lasts approximately 5 seconds occurs with turning head to right, tilting head, occurs with turning head to right, tilting head,

getting up quicklygetting up quickly

Pt. has 2 bulging discs in neckPt. has 2 bulging discs in neck

HBHB

Physical examPhysical exam

Audiologic evaluationAudiologic evaluation

Prior MRIPrior MRI

HB – Head-Hanging Right HB – Head-Hanging Right

HB – HHR repeatHB – HHR repeat

HB – Post TreatmentHB – Post Treatment

MPMP

51 year old female51 year old female

Fell off bicycle – loss of consciousnessFell off bicycle – loss of consciousness

Helmet cracked – fractured L temporal Helmet cracked – fractured L temporal bone, shoulder, and ribsbone, shoulder, and ribs L inner ear structures appeared normalL inner ear structures appeared normal

Small intracerebral bleedSmall intracerebral bleed

MPMP

Complains of mild vertigo Complains of mild vertigo when leaning backward when leaning backward or lying downor lying down

Dizziness passes quicklyDizziness passes quickly

Muffled hearing on left Muffled hearing on left sideside

Pt. had blood in left ear Pt. had blood in left ear canal, middle ear, and canal, middle ear, and mastoidmastoid

Treated with prednisoneTreated with prednisone

MPMP1 month later1 month later

L middle ear clear, but L middle ear clear, but hearing still muffledhearing still muffled

Persistent vertigo – lasts for Persistent vertigo – lasts for secondsseconds

Audiogram showed Audiogram showed improvement in L hearingimprovement in L hearing

VNG orderedVNG ordered

MP – Head-Hanging RightMP – Head-Hanging Right

MP – Head Hanging LeftMP – Head Hanging Left

MP – HHR repeatMP – HHR repeat

MP – Post TreatmentMP – Post Treatment

MP – Post Treatment MP – Post Treatment

Two days later – c/o different form of Two days later – c/o different form of dizzinessdizziness

Patient denied any side-lyingPatient denied any side-lying

Dizziness ranges from 5 to 8 on scale of 1 Dizziness ranges from 5 to 8 on scale of 1 to 10to 10

Four days post treatmentFour days post treatment

SMSM

56 year-old male56 year-old male

Complains of intermittent dizzinessComplains of intermittent dizziness

Left Dix-Hallpike Maneuver Left Dix-Hallpike Maneuver Downward and leftward torsional nystagmus after 5 Downward and leftward torsional nystagmus after 5

secondsseconds

Right Dix-Hallpike ManeuverRight Dix-Hallpike Maneuver Upward and rightward torsional nystagmus with Upward and rightward torsional nystagmus with

severe vertigosevere vertigo When returned upright nystagmus changed to When returned upright nystagmus changed to

downbeat torsionaldownbeat torsional

SMSM

Involvement of right posterior and left Involvement of right posterior and left anterior semicircular canals?anterior semicircular canals?

Central lesion?Central lesion?

SummarySummary

BPPV is easy to diagnose and treatBPPV is easy to diagnose and treat

Take an active role in the diagnosis and Take an active role in the diagnosis and

treatment of dizzinesstreatment of dizziness

Know your limitationsKnow your limitations

Multidisciplinary approachMultidisciplinary approach

ReferencesReferences

Goebel J. (Ed.) (2001) Goebel J. (Ed.) (2001) Practical Management of the Dizzy Patient.Practical Management of the Dizzy Patient. Philadelphia: Lippincott Williams & Wilkins.Philadelphia: Lippincott Williams & Wilkins.

Hain, T. (2007) Anterior Canal BPPV. Hain, T. (2007) Anterior Canal BPPV. http://www.dizziness-and-balance.com/disorders/bppv/anteriorbppv.htmhttp://www.dizziness-and-balance.com/disorders/bppv/anteriorbppv.htm

Herdman SJ, Tusa RJ. (2004) Herdman SJ, Tusa RJ. (2004) Diagnosis and Treatment of Benign Diagnosis and Treatment of Benign Paroxysmal Positional VertigoParoxysmal Positional Vertigo, Schaumburg: GN Otometrics., Schaumburg: GN Otometrics.

Jacobson G, Newman C, Kartush J. (Ed.) (1997) Jacobson G, Newman C, Kartush J. (Ed.) (1997) Handbook of Balance Handbook of Balance Function Function Testing. San Diego: Singular Publishing Group, Inc.Testing. San Diego: Singular Publishing Group, Inc.

Parnes L, Agrawal S, Atlas, J. (2003) Diagnosis and management of benign Parnes L, Agrawal S, Atlas, J. (2003) Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ, 169 (7), 681-693.paroxysmal positional vertigo (BPPV). CMAJ, 169 (7), 681-693.http://www.cmaj.ca/cgi/content/full/169/7/681#F716http://www.cmaj.ca/cgi/content/full/169/7/681#F716

Documents

Benign Paroxysmal Positioning Vertigo (BPPV) Tracy Murphy, Au.D