BENIGN PAROXYSMAL
POSITIONAL VERTIGO
WASEEM WATAD
Basic Anatomy
BPPV
Barany 1921
 Dix-Hallpike 1952 – important features
of nystagmus
 Abnormal sensation of motion elicited
by certain critical positions
 Provocative position  nystagmus
 At least 20% of vertigo
 Underestimated
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BPPV …
Subclassification : scc post/lat/ant/bilat
 Pathophysiology :
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– Canalithiasis
– cupulolithiasis
Pathophysiology
Pathophysiology (cont.)
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Cupulolithiasis :
– Harold Schuknecht 1962
– Densities (otocania) adherent to cupula of
crista ampullaris
– Basophilic particles -1969
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Canalithiasis :
– John Epley – 1980
– Densities free floating in canal portion
– Parnes , McClure – 1991 found particles in
post SCC
BPPV ...
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Frequency : 10-64/100000
Sex : 64% women
Age : older population ( 51-57)
younger than 35 – head trauma.
History :
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–
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sudden
days-weeks
occassionally months -years
episodes.
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Physical :
– neurological examination – normal
– except – Dix-Hallpike  pathognomonic
BPPV …
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Nystagmus : characterization and types
– RT / LT , vertical / horizontal , changing
– Tortional = Rotational – clockwise /
counterclockwise
– Geotropic- toward the earth
– Ageotropic – opposite
BPPV …
Classic post SCC – geotropic rotatory
nystagmus
 Horizontal SCC – purely horizontal
nystagmus
 Non-fatiguing nystagmus –
cupulolithiasis > canalithiasis
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Classic BPPV
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Involved the POST SCC
– Geotropic NG with affected ear down
– Rotatory , fast phase toward the
undermost ear
– Latency – few seconds
– Duration – limited < 20 seconds
– Reversal upon return upright position
– Response decline upon repetitive
provocation
Lat. SCC PPV
Most common atypical BPPV
 3-9% of cases
 Consequence of Epley maneuver
 Horizontal purely nystagmus
 Cupulolithiasis rather than canalithiasis
 Modified Epley / lampert maneuver …
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Lat. SCC PPV
Ant. SCC PPV
Rare – 2%
 Down-beating /torsional NG for the
opposite ear on Dix-Hallpike maneuver
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BPPV - Causes
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Predisposing factors :
– Inactivity
– Acute alcoholism
– Major surgery
– CNS disease
Causes ( cont. )
Idiopathic – 39%
 Ear disease – 29%
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– OM – 9%
– Vestibular neuritis – 7%
– Menier’s dis – 7%
– Otosclerosis – 4%
– Sudden SNHL – 2%
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Trauma – 21%
Causes ( cont. )
Trauma – 21%
 CNS diseases – 11%
 Acustic neuroma – 2%
 Cervical vertigo – 2%
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BPPV - D.D
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Menier’s disease
Inner ear concussion
Alcohol intoxication
Labyrinthitis
Vascular loop syndrome
Post. Fossa lesions : acustic neuroma ,
meningioma
Central origion : stroke , MS , cerebellar
degeneration
Vertibral artery insuffeciency
Cervical vertigo
BPPV - Treatment
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Watchful waiting
Vestibular suppressant medications
Vestibular rehabilitation
Canalith repositioning
Surgery care
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Labyrinthectomy
Post. Canal occlusion
Singula neurectomy
Transtympanic aminpglycoside application
Trials about BPPV
General
Labeled benign paroxysmal positional
vertigo is not always benign
 Evaluation of the effectiveness of
canalith reepositioning procedurs – CRP
 Several studies …
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Trials …
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Blakely – 1994 :
– 50% improvement in the control and CRP
group !! ( 2-3 months)
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Lynn – 1995 :
– Randomized-controlled : 89% negative DH
in CRP group , 27% in the control group
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John Li (1995) :
Trials…
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John Li (1995) :
– Comparison CRP / CRP + mastoid oscillation and
control
– Modified Epley maneuver
– Use of colar and head elevation after CRP
– No spontaneous resolution within aweek
– 60% symptoms improvement in CRP group
– 92% symptoms improvement in CRP +mastoid
oscilation and 70% negative DH
Trials…
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R. steenerson –1996 :
– Comparison of CRP and vestibular
habituation training
– Tow approaches are effective in
symptomatic relief ( 3 months)
– CRP faster relief and fewer treatments
Trials …
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K. Yimatae (2003)
– Randomized-controoled
– Modified Epley maneuver, no mastoid oscillator
and no instructions after the maneuver
– Subjective and objective weekly follow-up
– CRP group – 76% negative DH, 48% control
group
– CRP group – 96% symptoms improvement , 90%
control group
– Non-cured patients need > 6 procedures in 2
weeks , should considering liberatory maneuver
Elderly population and BPPV
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S. Angeli – 2003 :
– Effectiveness of CRP and VR
– Modified Epley :
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Elderly comorbidities : degenerative osteoarthritis
disease , CVA , peripheral neuropathy, cognitive and
autonomic dysfunctions
S/E of CRP – neck torsion and extension result in
vertibrobasilar artery insufficiency, strain on the spine
column, dislodged carotid a. emboli
Avoid liberatory maneuver
– 64% CRP group – negative DH after a month
– Overall 77% with CRP and VR
CRP Meta-Analysis
B. Woodworth - 2004
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CRP - First line of treatment
– Non-invasive
– Easy to perform in the office
– No need to expensive instrumentations
– Repeat maneuver if needed
– Potential to provide rapid relief of vertigo
Meta - Analysis
9 randomized-controlled trials
 Symptoms resolution and elimination of
positive Dix-Hallpike test
 CRP more effective than control ( x5 )
 Untreated patients - symptoms
improvements with time but positive DH
 So Resolution of vertigo – avoidance of
provocative positions
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CRP – Epley maneuver
CRP – Semont maneuver
Mastoid oscillator
Brandt-Daroff Exsercise
Lampert maneuver- Lat. SCC
BPPV
Vestibular rehabilitaions
Complications of CRP
Failure – 25% (12%-56)
 Recurrence – 13% in 6 months
 Side effects
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– Nausea
– Vomiting
– Fainting
– Sweating
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Worse vertigo – LAT SCC PPV
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THANK YOU …