BBPV Flashcards
(98 cards)
1
Q
head movements are categorized into 3 planes:
A
Yaw
Roll
Pitch
2
Q
Yaw =
A
Rotation around the vertical axis
Turning your head left and right (like saying “NO”)
Horizontal (Lateral) Canals
Roll Test (to test horizontal canal BPPV)
3
Q
Roll =
A
Rotation around the anterior-posterior axis
Tilting your head ear to shoulder (ear toward shoulder motion)
Primarily impacts perception of tilt; less direct canal testing, but can influence otolith organs (utricle/saccule)
4
Q
Pitch =
A
Rotation around the lateral (side-to-side) axis
Moving your head up and down (like nodding “YES”)
Anterior (Superior) Canal and Posterior Canal
Dix-Hallpike (posterior/anterior canal)
5
Q
Posterior Canal BPPV
plane of test =
A
Pitch (Dix-Hallpike)
You rotate the patient’s head 45° to one side (this is roll around the anterior-posterior axis).
Then you extend their neck back as you lay them down (this is pitch backward, along the side-to-side axis).
6
Q
Horizontal Canal BPPV
plane of test =
A
Yaw (Roll Test)
7
Q
Dix-Hallpike = Roll then Pitch.
A
(Turn head, then lay back into extension.)
Turning (roll) + extending (pitch) puts the posterior semicircular canal into a gravity-dependent position → so if otoconia are floating there, it triggers the typical torsional + upbeating nystagmus.
8
Q
BPPV, the most common ____ disorder, causes approx. ___% of “dizziness” in people 65 and older
A
vestibular
50
9
Q
Pathophysiology =
A
Otoconia become dislodged from the utricle and enter the semicircular canals
Head position in respect to gravity causes downwards movement of otoconial “clots” of debris, inducing an endolymphatic flow and cupular deflection which elicits the VOR
10
Q
Incorrect reflexive repositioning of the eyes causes the key symptom of BPPV ->
A
VERTIGO
11
Q
the otoconia only disrupt fluid mechanisms during movement =
A
therefore symptoms of vertigo should only occur during movement and resolve quickly
12
Q
BPPV: Symptoms
A
Type of “dizziness”: true vertigo
Circumstance: sudden head movements
Duration: less than 1-2 minutes
13
Q
diagnosis = dependent on
A
seeing specific nystagmus patterns during positional tests
NO relying on pt reported s/sx
need to see involuntary eye movements
14
Q
Differential Diagnosis =
A
BBPV
Vestibular neuritis
Labyrinthitis
Perilymphatic fistula
Chronic unilateral vestibular hypofunction
Drugs
Meniere disease
Acoustic Neuroma
15
Q
BBPV =
A
canaliths
brief bursts of vertigo, worse in am
brought on by movement
positive Dix-Hallpike
16
Q
Vestibular neuritis =
A
inflammation of CN VIII
severe and acute vertigo
associated with nausea
peaks in 1-2 days
17
Q
Labyrinthitis =
A
inner ear inflammation
similar to vestibular neuritis
associated with hearing loss
18
Q
Perilymphatic fistula =
A
barotrauma
intermitent vertigo
brought on by valsava
19
Q
Vestibular concussion =
A
head trauma
persistent vertigo
lasts months to years
20
Q
Chronic unilateral vestibular hypofunciton =
A
degeneration of vestibular apparatus
persistent and mild vertigo
can be progressive
21
Q
Drugs =
A
aminoglucosides
persistent vertigo
can be permanent
22
Q
Meniere disease =
A
excessive endolymph
intermittent vertigo
associated with tinnitus, decreased hearing and aural fullness
23
Q
Acoustic neuroma =
A
benign tumor of nerve
persistant, mild vertigo
unilateral hearing loss
24
Q
Posterior Canal BPPV
A
classic presentation (what you think of with sudden spinning when rolling over in bed).
Most common (~85-90%)
nystag = Up-beating + torsional (rotational)
test = Dix-Hallpike
treat = Epley maneuver
25
Horizontal (Lateral) Canal BPPV
ends to cause intense spinning when rolling side-to-side in bed; stronger symptoms than posterior sometime
~10% of cases
nystag = Pure horizontal nystagmus
test = Roll Test (Supine Head Roll)
treat = BBQ Roll (Log Roll maneuver) or Gufoni maneuver
26
Anterior (Superior) Canal BPPV
very rare and tricky
Rare (<5%)
nystag = Down-beating + torsional (or vertical)
test = Modified Dix-Hallpike
treat = Epley (modified for anterior), or Deep Head Hanging maneuver
27
Up-beating + torsional
Posterior canal BPPV
28
Pure horizontal nystagmus
Horizontal canal BPPV
29
Down-beating ± torsional
Anterior canal BPPV (or consider central pathology!)
30
Generally, correct BPPV diagnosis is dependent on ____
visualizing the correct nystagmus
31
Drugs that generally are considered to affect vestibular test results include:
sedatives (antihistamines, antiemetics, sleeping pills, barbiturates)
stimulants (caffeine, amphetamines)
rec drugs (alcohol, marijuana
amphetamines
tobacco
32
____ is a prescription drug (antihistamine) that suppresses the VOR to reduce vertigo symptoms
Meclizine (Antivert)
33
Therefore, it may be appropriate to ask patients/provider to withhold Meclizine for ____ prior to examination
24 hours
34
Currently, there are no universal guidelines that specify ____ a patient should refrain before vestibular testing
for how long or from which medications
35
Why do you want patients to withhold vestibular medications 24 hours before BPPV testing?
they depress the central nervous system (CNS) and/or suppress the vestibular-ocular reflex (VOR)
VOR is what causes nystagmus — if it's suppressed, you might not see the nystagmus during Dix-Hallpike or Roll Test, even if the patient has BPPV!
They also dull vertigo symptoms, meaning the patient might not report the normal strong positional vertigo sensation you expect
36
BPPV happens because otoconia (calcium carbonate crystals from the utricle) become dislodged.
Once they dislodge, where they end up — and how they behave — explains the two main theories:
Cupulolithiasis
Canalithiasis
37
Cupulolithiasis =
Otoconia stick to the cupula (the gelatinous sensory structure inside the ampulla of a semicircular canal)
The cupula becomes heavier than normal (because of the attached debris).
This changes the cupula’s response to gravity, making it sensitive to head positions even without head movement.
It causes continuous abnormal deflection of the hair cells when in certain positions.
38
Symptoms Based on Cupulolithiasis:
Immediate onset of vertigo when moved into provoking position (no latency).
Persistent nystagmus that lasts longer than 60 seconds while in the provocative position.
Symptoms don’t "fatigue" easily with repeated testing.
39
Cupulolithiasis Clinical Treatment:
Liberatory maneuvers (like Semont maneuver) are needed first to dislodge otoconia from the cupula.
Then, canalith repositioning can be used once it converts to canalithiasis.
40
___ = stuck debris = persistent symptoms.
Cupulolithiasis
41
Canalithiasis =
Otoconia are free-floating in the endolymph inside the semicircular canal (not stuck to the cupula).
Rapid head movements cause debris to move through the canal.
This movement creates endolymph flow, which deflects the cupula temporarily.
Once the debris settles, symptoms resolve because the flow stops
42
Symptoms Based on Canalithiasis:
Latency: Symptoms begin a few seconds (1–5 seconds) after moving into the provoking position.
Brief duration: Nystagmus/vertigo typically lasts < 60 seconds.
Symptoms fatigue (get less intense) with repeated testing.
43
Canalithiasis Clinical Treatment:
Canalith repositioning maneuvers (Epley, BBQ roll) are used to guide debris back to the utricle.
44
___ = floating debris = brief, delayed symptoms.
Canalithiasis
45
Most cases of BPPV are now believed to be ___.
canalithiasis
46
Canalithiasis vs Cupulolithiasis
occurs:
Both mechanisms can coexist — sometimes particles initially stick to the cupula and later detach into the canal
47
Canalithiasis vs Cupulolithiasis
symptom latency =
can = Yes (1-5 sec delay)
cup = None (immediate onset)
48
Canalithiasis vs Cupulolithiasis
symptom duration =
can = <60 sec (brief)
cup = >60 sec (persistent)
49
Canalithiasis vs Cupulolithiasis
nystagmus fatigue =
can = Yes (gets less intense)
cup = No (persistent with repeated tests)
50
Canalithiasis vs Cupulolithiasis
treatment =
can = Epley/BBQ (repositioning)
cup = Liberatory maneuver first
51
"_____ = sticky, stubborn, stays."
Cupulolithiasis
52
"____ = floating, fleeting, fixable."
Canalithiasis
53
What is the Vertebral Artery Test?
screen for vertebrobasilar insufficiency (VBI) — which is reduced blood flow through the vertebral arteries that supply the brainstem and cerebellum
54
If the vertebral arteries are compromised (due to stenosis, injury, etc.), extending and rotating the neck (like you do during positional testing) could:
worsen blood flow → leading to serious symptoms (fainting, stroke risk)
55
So you do the Vertebral Artery Test before ___ to make sure it's safe to extend and rotate their neck
positional tests (like Dix-Hallpike)
56
How to Perform the Vertebral Artery Test:
1. Patient seated (or sometimes supine, but seated is common in vestibular screens).
2. Extend the patient's neck gently (look upward).
3. Rotate the head fully to one side.
4. Hold this position for about 10 seconds while observing:
Eyes
Facial expressions
Ask about symptoms (dizziness, nausea, visual changes)
5. Return to neutral.
6. Repeat on the other side.
57
Positive Test = Signs of Vertebrobasilar Insufficiency:
Dizziness
Diplopia (double vision)
Dysarthria (slurred speech)
Dysphagia (difficulty swallowing)
Drop attacks (sudden loss of postural tone)
Nystagmus
Nausea
Loss of consciousness or feeling faint
If positive ➔ Do NOT proceed with Dix-Hallpike or other positional testing.
✅ Patient needs referral for medical clearance first.
58
The Vertebral Artery Test has low sensitivity and specificity — meaning
a negative test does NOT guarantee the arteries are normal
BUT it's still a standard of care screen in vestibular rehab and positional testing to catch any obvious red flags.
If suspected trauma: sharp purser + alar ligament tests
59
Variety of patient positions that isolate each vestibular canal in a ___ position
gravity dependent
60
If you expect BPPV from a subjective history:
do NOT perform other vestibular or ocular motor tests first (see algorithms)
BPPV can cause you to have inaccurate findings
61
BPPV Examination: Posterior & Anterior Canals
____ is gold standard
Positive Test:
Dix-Hallpike
Torsional AND upbeating nystagmus
62
Must hold position ___
30 seconds!
63
Dix-Hallpike test:
1) pt sits w/ head turned 45 + eyes wide up
2) PT leans pt back w/ one ear pointed to ground (stays 1-2 min)
3) pt eyes checked for nystagmus
**hold position for 30 seconds - even if s/sx start immediately
64
Treatment ____ = BPPV Posterior Canal
Canalith Repositioning Procedure-Epley
65
Epley Maneuver Purpose:
Treat posterior canal canalithiasis (the most common form of BPPV).
Goal = move free-floating otoconia out of the posterior semicircular canal and back into the utricle, where they won’t trigger abnormal endolymph flow anymore.
✅ Free-floating debris ➔ repositioned safely ➔ vertigo stops.
66
When to Use Epley:
Positive Dix-Hallpike test with:
Up-beating + torsional (rotary) nystagmus
No major cervical contraindications (neck cleared)
67
Steps of the Epley Maneuver:
Starting position: Patient sitting upright, head turned 45° toward affected side.
Lay patient back quickly with head still turned 45° toward affected side and neck extended about 20–30°
Hold for 30-60 sec
Rotate head 90° toward the unaffected side (without lifting up)
Roll onto side (unaffected side down), with head turned down 45° (looking toward floor)
Slowly help patient sit up
✅ Hold each position 30 seconds or until symptoms subside before moving to the next!
68
Warn the patient that they might feel vertigo during the maneuver —
that’s expected and means it’s working!
69
Why Each Movement Matters:
First lay-back:
Head turn to unaffected side:
Rolling onto side:
Sitting up:
First lay-back: Debris falls into posterior canal.
Head turn to unaffected side: Moves debris along the canal.
Rolling onto side: Gravity helps debris exit the canal.
Sitting up: Completes debris relocation into the utricle.
70
Epley Contraindications to Be Aware of:
Severe cervical spine disease
Severe vascular disease (vertebral-basilar insufficiency)
Carotid stenosis
Recent neck or back surgery
Severe orthostatic hypotension
Always clear the neck first before performing Epley!
71
_____: Alternative for Treatment of PSC/ASC BPPV
Semont Meneuver
72
Semont Meneuver
Purpose:
Treat posterior canal BPPV (and sometimes anterior canal BPPV).
Especially useful for cupulolithiasis (when the otoconia are stuck to the cupula instead of floating freely).
Liberatory maneuver = designed to "break loose" stuck otoconia.
✅ Goal = Dislodge otoconia from the cupula so they can move freely and then be repositioned by normal movements.
73
Steps of the Semont Maneuver:
Patient sitting upright on exam table; head turned 45° toward the unaffected (healthy) side.
1. Quickly move patient onto the affected side, lying down sideways
2. Hold for ~30 seconds
3. Quickly move patient to lie on the opposite side, WITHOUT changing head position (still turned the same way)
4. Hold for ~30 seconds
5. Slowly sit back up
74
Sermont keys =
✅ Important: These movements are much faster than in Epley.
✅ It’s supposed to create a "whip" or "jerk" of the otoconia to free them from the cupula.
Support the patient’s head and trunk tightly — movements need to be fast but controlled and safe.
You do not rotate the head after starting — the head stays turned the entire time.
Watch out for strong vertigo or nausea between side transitions (it can be intense).
75
When is Semont better than Epley?
When you suspect cupulolithiasis (persistent nystagmus >60 sec).
If patient cannot tolerate laying back slowly into extension (like in Dix-Hallpike/Epley).
If previous Epley attempts haven’t worked.
If you need to use a more aggressive approach to detach debris.
76
Semont Maneuver is a ___ "____" technique that uses quick side-to-side motions to break otoconia loose from the cupula in stubborn posterior or anterior canal BPPV.
fast
liberation
77
BPPV Examination: Horizontal/Lateral Canal
____ is gold standard
Roll test
Positive Test: px side is determined based on which side has stronger nystagmus response
Hold position 30 seconds
78
Roll Test (Supine Head Roll Test) =
patient lies supine (flat)
you rotate the head 90° to one side - look for nystagmus - face up
rotate the head 90° to other side - look for nystagmus - face up
79
___ = nystagmus beats toward the ground
Geotropic
80
___ = nystagmus beats away from the ground
Apogeotropic
81
Geotropic BPPV:
(more common)
Otoconia floating freely in canal (canalithiasis)
Nystagmus beats toward the ground on both sides
Stronger side = affected ear
82
Apogeotropic BPPV:
(less common)
Otoconia stuck on cupula (cupulolithiasis)
Nystagmus beats away from the ground on both sides
Weaker side = affected ear
83
When You Turn Head To...
Affected ear (if Geotropic)
Stronger nystagmus, toward ground
Canalithiasis (free-floating debris)
84
When You Turn Head To...
Unaffected ear (if Geotropic)
Weaker nystagmus, toward ground
85
When You Turn Head To...
Affected ear (if Apogeotropic)
Weaker nystagmus, away from ground
Cupulolithiasis (stuck debris)
86
When You Turn Head To...
Unaffected ear (if Apogeotropic)
Stronger nystagmus, away from ground
87
You do a Roll Test:
Roll head to right: strong geotropic (ground-beating) nystagmus
Roll head to left: weak geotropic nystagmus
Diagnosis:
Geotropic BPPV (canalithiasis)
Right ear is affected (stronger side = bad side)
88
Log Roll Maneuver (BBQ Roll)
Purpose:
Treat horizontal (lateral) canal BPPV — usually canalithiasis (free-floating debris).
The goal is to rotate the otoconia 360° around the head using gravity, moving them back to the utricle.
✅ It's called "BBQ Roll" because the patient is slowly "rotisserie rolled" like a barbecue spit!
89
When to Use Log Roll Maneuver (BBQ Roll) :
After a positive Roll Test (supine head roll) showing horizontal nystagmus.
Geotropic (toward the ground) nystagmus usually = canalithiasis, best treated with BBQ Roll.
90
Steps of the Log Roll (BBQ Roll) Maneuver:
Patient lying supine (on back), head turned toward affected side.
Roll head to neutral (face up)
Roll head to unaffected side
Roll whole body onto side (unaffected side down)
Patient rolls onto stomach, face down (prone)
Sit up slowly
✅ Hold each position ~15–30 seconds or until vertigo/nystagmus subsides before moving to the next!
91
Clinical Tips for BBQ Roll:
Move slowly and steadily — unlike Semont, BBQ Roll is controlled, not fast or jerky.
Support the patient carefully — some people get very dizzy mid-roll.
Patients may need help coordinating the full body rolls — explain each move before you do it.
Some protocols allow pausing at each 90° position to allow debris to settle fully.
92
Gufoni Maneuver
Purpose:
Treat horizontal canal BPPV.
Especially useful if the patient can't tolerate the multiple full-body rolls of the BBQ roll.
Works for both:
Geotropic horizontal canal BPPV (canalithiasis)
Apogeotropic horizontal canal BPPV (cupulolithiasis)
93
Gufoni = easier, faster alternative to the BBQ roll, especially for:
older, injured, or nauseous patients
94
When to Use: Gufoni
Positive Roll Test (supine head roll) showing horizontal nystagmus.
Decide which type:
Geotropic → debris is free-floating.
Apogeotropic → debris stuck to cupula.
✅ Different slight head angles are used depending on which one!
95
Steps for the Gufoni Maneuver (Geotropic Variant):
1. Patient sits upright
2. Quickly lie down onto unaffected side
3. After lying down, turn head 45° downward (toward bed/floor)
4. Hold for ~1-2 minutes
5. Slowly return to sitting
96
Steps for Gufoni (Apogeotropic Variant):
1. Sit upright
2. Quickly lie onto affected side (not unaffected!)
3. After lying down, turn head 45° upward (toward ceiling)
4. Hold for ~1-2 minutes
5. Sit up slowly
97
Key Difference:
Geotropic ➔
Apogeotropic ➔
Geotropic ➔ lie on unaffected side, turn head down.
Apogeotropic ➔ lie on affected side, turn head up.
98
Gufoni uses gravity to shift the otoconia either ____ or ____
away from the cupula
through the canal toward the utricle
