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Benign Paroxysmal Positional Vertigo (Bppv)

Essentials

  • Benign paroxysmal positional vertigo (BPPV) is the most common vertigo inducing vestibular disorder.
  • As the name suggests, in this condition vertigo is benign and not caused by a serious central nervous system disease.
  • Diagnosis is based on the patient's history and clinical findings.
  • The patient is informed of the benign nature and good prognosis of the condition and is encouraged to move around freely.

Prevalence and significance

  • BPPV is most common in middle aged and elderly people. It can, however, also affect younger individuals particularly following a head trauma.
  • About 25% of all patients who present with vertigo have BPPV.
  • Undiagnosed and untreated BPPV significantly impairs the patient's functional capacity, mood and quality of life. If left untreated BPPV may cause an elderly patient to be admitted to a care facility as he/she becomes prone to falls, which may lead to a hip or other fracture, and is no longer able to cope at home. Patients of working age may, for example, need to be absent from work.

Pathophysiology

  • The vestibular system is located in the inner ear and consists of three fluid-filled semicircular canals and two membranous swellings, the saccule and the utricle.
  • The saccule and the utricle are also known as the otholith organs. When debris that forms within these organs travels to the semicircular canals the person experiences vertigo that is associated with head rotation.
  • In about 85-95% of cases BPPV is caused by debris collecting in the posterior semicircular canal in the inner ear.
  • Risk factors and possible contributing factors include female sex, osteoporosis, vitamin D deficiency, high blood pressure, diabetes, advanced age, physical inactivity, Ménière's disease and head injuries.

Diagnosis

  • BPPV is diagnosed when the patient gives a typical history and the Dix-Hallpike test is positive.
  • The patient has posterior semicircular canal BPPV when
    • the patient describes repeated episodes of vertigo associated with turning of the head or changing position
    • the Dix-Hallpike test provokes typical nystagmus with a latency of 5-20 seconds and beating towards the affected ear. With repeat testing, the response declines; the vertigo and nystagmus usually resolve within one minute.
      • Before the test is carried out, the different stages of the test should be explained to the patient. A neck injury or other skeletal problem that would prevent carrying out the test must be excluded.
      • The test: The patient sits initially on the examination table, and the examiner rotates the patient's head by 45° to the right. The examiner then helps the patient to lie down backwards quickly on the right ear with the head held in slight extension (about 20° below the horizontal level). The examiner observes the patient's eyes for possible nystagmus noting its latency, direction and duration. The patient is also asked about vertigo and how he/she is feeling. The test is repeated on the left side. Frenzel goggles may be used during the test; they prevent the patient from achieving visual fixation and they assist the examiner in observing an even slight nystagmus.
      • The test also often reveals a so-called reverse nystagmus when the patient gets back to a sitting position. In this case, the nystagmus is rotatory, with the nystagmus beating downwards towards the healthy ear. The observation of this helps in the BPPV diagnosis of the posterior semicircular canal.
  • Imaging studies, laboratory investigations, hearing tests and balance studies yield no extra information for the diagnostics. They are only of benefit for the purposes of differential diagnosis if the diagnosis remains unconfirmed.

Differential diagnosis

  • Vertigo (see also Vertigo Vertigo) may be caused by a variety of aetiologies.
    • Ménière's disease is accompanied by ear symptoms, fluctuating hearing loss and the episodes last longer.
    • In vestibular neuritis and labyrinthitis the symptom duration is longer, i.e. from several days to weeks.
    • A perilymphatic fistula causes vertigo particularly with pressure changes.
    • In superior semicircular canal dehiscence, i.e. absence of the part of the temporal bone overlying the superior semicircular canal, loud sounds may cause vertigo.
    • Post-traumatic vertigo is rarer, and the clinical picture may include headache, tinnitus, altered hearing and dizziness.
    • Vertigo induced by migraine, multiple sclerosis (MS) or tumours
    • Cerebellar infarction; symptoms other than vertigo are usually present
    • Panic disorder, orthostatic hypotension, adverse effects of medication (e.g. antihypertensive drugs, antiepileptics) and shoulder/neck tension

Treatment

  • Various bedside manoeuvres (repositioning procedures) are available for the treatment of posterior semicircular canal BPPV. The most commonly used ones are the Epley manoeuvre Epley Manouvere for Benign Paroxysmal Positional Vertigo and the Semont manoeuvre (see e.g. http://www.physio-pedia.com/Benign_Positional_Paroxysmal_Vertigo_(BPPV) and http://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/home-epley-maneuver).
  • Repositioning procedure therapy has proven to be more effective than exercise training and pharmacotherapy. If the treatment response remains poor, repeating the repositioning procedures is effective.
    • A large share of patients, however, get well already after the first repositioning procedure.
    • BPPV may recur even after an asymptomatic period of months.
  • The Lempert manoeuvre is used in the treatment of lateral semicircular canal BPPV.
  • A motivated patient may be instructed to carry out the positional exercises at home (give printed patient handout). For the success of the treatment, a physiotherapist well versed in these manoeuvres plays an important role.
  • Avoiding and treating risk factors and exercising help prevent postural paroxysmal positional vertigo.
  • Vestibulosuppressant medication and anxiolytics do more harm than good.
  • In severe treatment-resistant cases, an ear specialist should be consulted.

    References

    • Chen J, Zhang S, Cui K, et al. Risk factors for benign paroxysmal positional vertigo recurrence: a systematic review and meta-analysis. J Neurol 2021;268(11):4117-4127 [PubMed]
    • Walter J, Azeredo WJ, Greene JS, et al. Prevalence of "Reversal Nystagmus" in Benign Paroxysmal Positional Vertigo. J Am Acad Audiol 2021;32(1):35-38 [PubMed]
    • Laurent G, Vereeck L, Verbecque E, et al. Effect of age on treatment outcomes in benign paroxysmal positional vertigo: A systematic review. J Am Geriatr Soc 2021; Oct 26, Online ahead of print. [PubMed]
    • von Brevern M, Bertholon P, Brandt T, et al. Benign paroxysmal positional vertigo: Diagnostic criteria Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society. Acta Otorrinolaringol Esp 2017;68(6):349-360. [PubMed]
    • Liu Y, Wang W, Zhang AB, et al. Epley and Semont maneuvers for posterior canal benign paroxysmal positional vertigo: A network meta-analysis. Laryngoscope 2016;126(4):951-5. [PubMed]
    • Reinink H, Wegner I, Stegeman I, et al. Rapid systematic review of repeated application of the epley maneuver for treating posterior BPPV. Otolaryngol Head Neck Surg 2014;151(3):399-406. [PubMed]
    • Amor-Dorado JC, Barreira-Fernández MP, Aran-Gonzalez I, et al. Particle repositioning maneuver versus Brandt-Daroff exercise for treatment of unilateral idiopathic BPPV of the posterior semicircular canal: a randomized prospective clinical trial with short- and long-term outcome. Otol Neurotol 2012;33(8):1401-7. [PubMed]