Common cause of dizziness.
Is by far the most common type of dizziness.
Caused by the presence of calcium-containing, otolithic membrane debris in one or more of the semicircular canals.
On average, about 1.6% of the population has BPPV each year, of whom about 0.6% had it begin that year.
About 20% of all dizziness seen in medical offices.
Is rare in children.
Incidence increases linearly with age.
About 50% of all dizziness in older people is due to BPPV.
In one study, 9% of a group of urban dwelling elders were found to have undiagnosed BPPV (Oghalai et al., 2000).
The peak age for BPPV is roughly 60.
Above the age of 60, approximately 3.4% of the population has BPPV every year.
The symptoms include dizziness or vertigo, lightheadedness, imbalance, and nausea.
Symptoms are almost always precipitated by a change of position of the head with respect to gravity.
Getting out of bed or rolling over in bed are common problems.
An intermittent pattern is common.
The most common cause is degeneration of the vestibular system of the inner ear, involving the otoliths.
The most common cause of BPPV in people under age 50 is head injury.
Whiplash injuries have a substantial incidence of BPPV.
Between 8% and 20% of cases is attributed to trauma.
Can follow surgery, including dental work, where the cause is felt to be a combination of a prolonged period of supine positioning with vibration from drilling, or after surgery to the inner ear.
The resolution rate of BPPV due to trauma and nontraumatic BPPV is similar.
There is also a strong association with migraine, and viral diseases
affecting the ear such as those causing vestibular neuritis and Meniere’s disease are significant causes.
Common in persons who have been treated with ototoxic medications such as gentamicin.
Can make the diagnosis based on history, findings on physical examination, and the results of vestibular and auditory tests.
Often, the diagnosis can be made with history and physical examination alone.
In the Dix-Hallpike test a person is brought from sitting to a supine position, with the head turned 45 degrees to one side and extended about 20 degrees backward.
A positive Dix-Hallpike tests consists of a burst of nystagmus.
The Dix-Hallpike test it is highly sensitive to and specific for benign paroxysmal positional vertigo.
Historically the key observation is that dizziness is triggered by lying down, or rolling over in bed.
Electronystagmography (ENG) testing may be needed to look for the characteristic nystagmus induced by the Dix-Hallpike test.
A rotatory chair test may be used for difficult diagnostic problems.
Symptoms often subside or disappear within 1-2 months of onset.
Motion sickness medications are sometimes helpful in controlling the nausea but are otherwise rarely beneficial.
Two treatments of BPPV are very effective, with roughly an 80% cure rate.
The maneuvers are both intended to move debris or “ear rocks” out of the sensitive posterior canal to a less sensitive location.
Each maneuver takes about 15 minutes to complete.
The Semont maneuver involves a procedure whereby the patient is rapidly moved from lying on one side to lying on the other.
The Semont maneuver is 90% effective after 4 treatment sessions.
It is equivalent to the Epley maneuver as the head orientation with respect to gravity is very similar.
The Epley maneuver is also called the canalith repositioning procedure.
https://www.youtube.com/watch?v=BtT2PDJVXlk
The Epley maneuver involves sequential movement of the head into four positions, staying in each position for roughly 30 seconds.
The recurrence rate for BPPV after maneuvers is about 30 percent at one year, and in some instances a second treatment may be necessary.
During the Epley maneuver, caution is advised should neurological symptoms occur, as such symptoms can be caused by compression of the vertebral arteries precipitating a stroke.
Usually one allows 30 seconds between positions.
The Epley maneuver works roughly 50-75% of the time on the first occasion.
IN 25% of cases they are not improved fixed or only partially better.
In about about 5% of cases patients are worse.
Maneuvers for BPPV, on 2 or 3 occasions, are effective in 85-95% of patients.
When all maneuvers have been tried, the diagnosis is clear, and symptoms are still intolerable, surgical management may be offered.
Often recurs, with about 1/3 of patients have a recurrence in the first year after treatment, and by five years, about half of all patients have a recurrence.
In some positional vertigo can be eliminated but imbalance persists, and this may be related to utricular damage.
The frequency of surgical treatment has been dropping.
Only about 1/200 have surgery.
Surgery should not be considered until all three maneuvers/exercises have been attempted and failed.
Surgical treatment of BPPV has a 3% risk of unilateral hearing loss.
Surgical indications: if the exercises described above are ineffective in controlling symptoms, and
symptoms have persisted for a year or longer
The surgical procedure is a posterior canal plugging.
Canal plugging blocks most of the posterior canal’s function without affecting the functions of the other canals or parts of the ear.
Canal plugging poses a substantial risk to hearing, ranging from 3-20%, but is effective in about 85-90% of individuals
The risk of the surgery occurs from inadvertent breaking into the endolymphatic compartment while attempting to open the bony labyrinth with a drill.
Singular nerve section is the main alternative surgery, but is very difficult because it can be hard to find the singular nerve.
There are several rare variants, thought to be caused by migration of otoconial debris into canals other than the posterior canal, such as the anterior or lateral canal.
Debris may also migrate into or out of the short arm of the posterior canal.
Lateral canal BPPV is the most common atypical BPPV variant, accounting for about 3-12 percent of cases.
Anterior canal BPPV is rare, and accounts for about 2% of cases of BPPV.
Prevalence between 10.7 and 64 cases per 100,000 population.
Lifetime prevalence of 2.4%.
Characterized by brief spinning sensations usually lasting less than a minute.
Process is generally induced by a change inhead position with respect to gravity.
Responsible for about 20% of all cases of dizziness.
Can occur in children but the older one is the more likely dizziness due to BPPV.
About 50% of all cases of dizziness in older people due to BPPV.
Approximately 9% of urban dwelling elderly have undiagnosed disease.
Dizziness due to debris collected in the inner ear.
Debris known as “ear rocks”, consisting of calcium carbonate crystals derived from the utricle.
The saccule also contains otoconia, but they are not able to migrate into the canal system.
Utricle may have sustained injury from head trauma, infection or degeneration related to age.
Otoconia (ear stones) have slow turnover and are probable dissolved and reabsorbed by the labyrinth found in the adjacent utricle and the crista.
Normal otoconia have a very slow turnover, probably not fast enough to replace loss due to age or trauma.
Loose otoconia are probably dissolved actively reabsorbed by the labyrinth which are found adjacent to the utricle and the crista.
Symptoms include vertigo, lightheadedness, imbalance, and nausea.
Vertigo typically develops when the patient gets in or out of bed, tilts their head backwards, rolls over in bed, or bends forward.
Occasionally patients report persistent dizziness and imbalance, but adequate history indicates that symptoms are worse with change and head position.
Some patients experience nausea and vomiting.
Events have no specific cause, although they maybe associated with head trauma, prolonged recumbent position, or disorders of the ear.
Spontaneous remission and recurrences are frequent.
Annual rate of recurrence is approximately 15%.
Patients are at increased risk for falls and impaired performance of daily activities.
Symptoms almost always precipitated by changes in position of the head with respect to gravity.
Commonly has an intermittent pattern being present for a few weeks and the stopping, only to come back again.
Most common cause under age 50 years is head trauma.
May be associated with migraine.
In the elderly associated with degeneration of the vestibular system of the inner ear.
Rarely caused by viruses, minor strokes, and Meniere’s disease.
May follow surgery with prolonged period of supine positioning and when there is surgery to the inner ear.
Common following usage of ototoxic medications.
Diagnosis usually made with history and physical examination alone.
Diagnosis utilizes the Dix-Hallpike test when a patients is brought from the sitting to a supine position, with the head turned 45 degrees to one side and extended about 20 degrees backward and consists of a burst of nystagmus with twisting and jumping of the eye.
Dizziness triggered by laying down or by rolling over in bed.
Most other cases of positional dizziness are worse on standing rather than on lying down.
Can be confused with spinocerebeller ataxia.
Electronystagmograpy can measure vertical eye movements and can establish the diagnosis during the Dix-Hallpike test.
Bilateral disease is uncommon with less than 5% of patients so affected.
Symptoms usually subside or disappear within 2 months, but may last much longer.
Symptoms wax and wane.
Treatment with maneuvers to remove debris from the posterior canal to a less sensitive location is associated with 80% cure rate.
The Semont maneuver involves the rapid movement of the patient from lying on one side to lying on the other with 90% effectiveness after 4 treatment sessions.
The Epley maneuver involves the sequential movement of the head in four positions, staying in each position for 30 seconds.
Recurrence rate at 1 year is about 30% and may require a repeat maneuver for resolution.