BPPV Benign Paroxysmal Positional Vertigo: A Summary for GP’s
Definition:
Recurrent attacks of positional vertigo, typically lasting less than one a minute
Provoked by positional change of the head, for example: turning over in bed, lying down, neck extension, bending forward.
May have associated nausea, vomiting, sweating,.
Hearing loss, tinnitus, aural fullness/pressure are not associated with BPPV
Diagnosis
Diagnosis is by positional testing which reproduces provokes vertigo and canal specific nystagmus.
Diagnosis includes the specification of the affected semicircular canal(s) and the pathophysiology (canalithiasis or cupulolithiasis).
Clinical features essential for the diagnosis are the latency, direction, time course, and duration of positional nystagmus.
Usually, further vestibular and auditory testing is indicated only when a pre-existing disorder of the inner ear (e.g. vestibular neuritis, Menière’s disease) is suspected.
Brain or ear imaging is not required in typical cases of BPPV.
Treatment:
Canalith Repositioning Manoeuvres typically done by a Physiotherapist with an interest in Vestibular Rehabilitation (Helen Sibbald has experience & a special interest in this)
BPPV Information
The posterior canal is the most frequently affected canal (80– 90%); next is the horizontal canal (5–30%). Involvement of the anterior canal is rare.
1. Canalithiasis of the posterior canal.
Diagnostic criteria:
A) Recurrent attacks of positional vertigo or positional dizziness provoked by lying down or turning over in the supine position.
B) Duration of attacks < 1 min.
C) Positional nystagmus elicited after a latency of one or few seconds by the Dix-Hallpike manoeuvre or side-lying manoeuvre (Semont diagnostic manoeuvre). The nystagmus is a combination of torsional nystagmus with the upper pole of the eyes beating toward the lower ear combined with vertical nystagmus beating upward (toward the forehead) typically lasting < 1 minute.
D) Not attributable to another disorder.
Note:
Usually, the duration of positional nystagmus is no longer than 40 seconds before it dampens spontaneously.
Positional nystagmus rapidly increases in intensity and then declines more slowly (crescendo-decrescendo type)
After the patient returns to the upright position, positional nystagmus with reversed direction of lesser intensity and shorter duration often occurs.
Fatigability of nystagmus and vertigo with repetitive positional testing is common.
The direction of nystagmus is essential to specify the affected canal. In contrast to central positional nystagmus, positional nystagmus in BPPV always beats in the plane of the affected canal and in the expected direction for canal excitation or inhibition.
History and physical and neurological examinations do not suggest another vestibular disorder – or such a disorder is considered, but ruled out by appropriate investigations – or such disorder is present as a comorbid condition that can be clearly differentiated
Assessment: It is essential to perform positional manoeuvres for both the vertical and the horizontal semicircular canals in every patient with positional vertigo as multiple canals may be affected .
Dix Hallpike manoeuvre or Semont diagnostic manoeuvre tests the vertical canals and the supine roll test for the horizontal canals.
For observation of positional nystagmus, Frenzel goggles or video-oculography can be helpful, particularly when the nystagmus is weak or momentary. In most cases, however, nystagmus can be seen clinically without special equipment.
The differential diagnosis of BPPV includes central positional vertigo due to vestibular migraine and structural brainstem and cerebellar lesions. CNS disease can usually be excluded by a thorough neurological examination.
Greater care should be taken in patients with dominantly horizontal or downbeat positional nystagmus forms, since these are most frequently reported in central mimics.
Cerebral imaging with MRI is usually only indicated when symptoms or signs of concurrent brainstem or cerebellar dysfunction are present, or when positional vertigo and nystagmus present with atypical features or fail to resolve with repeated therapeutic positional manoeuvres.
Treatment: Epley manoeuvre
2. Cupulolithiasis of Posterior canal:
Diagnostic criteria:
A. Recurrent attacks of positional vertigo or positional dizziness provoked by lying down or turning over in the supine position.
B. Positional nystagmus elicited after a brief or no latency by a Dix-Hallpike manoeuvre beating torsionally with the upper pole of the eye to the lower ear and vertically upward (to the forehead) and lasting > 1 min.
C. Not attributable to another disorder.
Treatment: Semont Liberatory Manouevre
3.Canalithiasis of the horizontal canal
Diagnostic criteria
A. Recurrent attacks of positional vertigo or positional dizziness provoked by lying down or turning over in the supine position and head rotation, extension, flexion in erect position.
B. Duration of attacks < 1 min.
C. Positional nystagmus elicited after a brief latency or no latency by the supine roll test , beating horizontally toward the undermost ear with the head turned to either side (geotropic direction changing nystagmus) and lasting < 1 min.
D. Not attributable to another disorder.
Note: During the supine roll test, the faster the head turn, the shorter the latency and the higher the intensity of nystagmus. The intensity of nystagmus tends to be higher with larger head rotations.
To confirm the affected ear: the intensity of nystagmus is usually stronger with the head turned to the affected ear in the supine roll test. The Bow and Lean test: nystagmus beating toward the affected ear in the bow position and nystagmus beating toward the healthy ear in the lean position.
Transition from geotropic to apogeotropic nystagmus may occur during diagnostic and therapeutic manoeuvres. Transition of canalithiasis from the posterior canal to the horizontal canal may occur as a result of therapeutic positional manoeuvres.
Treatment: BBQ roll or Gufoni for Geotrophic variant
4.Cupulolithiasis of the horizontal canal:
Diagnostic criteria:
A. Recurrent attacks of positional vertigo or positional dizziness provoked by lying down or turning over in the supine position.
B. Positional nystagmus elicited after a brief latency or no latency by the supine roll test, beating horizontally toward the uppermost ear with the head turned to either side (apogeotropic direction changing nystagmus), and lasting > 1 minute.
2. Not attributable to another disorder.
Note: As direction-changing apogeotropic positional nystagmus also occurs as a sign of central-vestibular dysfunction, it is mandatory to exclude CNS disease.
The side of the affected ear: The intensity of positional nystagmus is usually stronger with the head turned away from the affected ear in the supine roll test.
Apogeotrophic direction changing positional nystagmus may also occur with canalithiasis of the horizontal canal where otoconia are located in the anterior part of the horizontal canal (transient nystagmus, not persistant like cupulolithiasis)
Treatment: Gufoni for Ageotrophic variant or Casani Manouevre
Link for the Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society -BPPV:
Vesticam Googles for accurate nystagmus diagnosis
Gold Coast Physio & Sports Health has infrared video googles to enable our Physio’s to visualise abnormal eye movements during testing of patients complaining of vertigo. Having best practice technology allows us to more accurately diagnose and therefore choose best treatment pathways & better outcomes.
BBPV has a very classic presentation of vertigo with Nystagmus that beats in a certain predicatable direction for the particular affects semi-circular canal, and it latent plus fatigues. So the affected semi-circular canal can be accurately identified with the Googles and therefore the correct treatment manoeuvre used.
Not every patients experiencing positional Verigo has BBPV. If, for example, the patient experiences vertigo on BPPV testing but has a persistent nystagmus is observed, this is NOT BPPV, but rather central positional vertigo, and the underling central cause would need to be identified with further investigation/ MRI. Googles make it accurate to observe the direction of nystagmus, and the movement is recorded to watch and check repeatedly, or to pass on to other Specialists for accuracy in diagnosis.