Benign Paroxysmal Positional Vertigo

Question 1

Definition

Answer 1

Short lived episodes of vertigo elicited by head perturbation. Classified as a peripheral vestibular disorder

Question 2

Epidemiology

Answer 2

Increasing age: >50 years
Female
Head trauma: direct damage to the utricle cause otolith displacement
Inflammation: labyrinthitis and vestibular neuritis can cause otolith displacement
Migraines: labyrinth artery vasospasm can cause otolith displacement

Question 3

Pathophysiology

Answer 3

The labyrinth in the inner ear contains calcium crystals - otoliths. BPPV = migration of otoliths from the utricle into the semicircular canals. Posterior canal is most commonly affected.

Question 4

Signs

Answer 4

Positive Dix-Hallpike manoeuvre - assess for torsional nystagmus whereby the eye rotates towards the affected eat. Nystagmus is fatiguable and lasts for up to 1 minute
Positive supine lateral head turn - suggests lateral canal BPPV
Normal neurological examination

Question 5

Symptoms

Answer 5

Episodes of spinning dizziness:
- Sudden and severe < 30 seconds
- Episodic and occur on head movement
Triggers:
- Rolling over in bed
- Reclining
- Gazing upwards
Nausea and vomiting: often persist for longer

Question 6

Diagnosis

Answer 6

Positive Dix-Hallpike manoeuvre
Positive supine lateral head turn

Question 7

Differential diagnosis

Answer 7

Ménière’s disease - triad of tinnitus, hearing loss and aural fullness. Vertigo lasts hours
Labrinthitis - preceding viral infection and hearing loss lasting days
Vestibular neuritis - preceding viral infection with vertigo lasting days, no hearing loss

Question 8

Management

Answer 8

FIRST LINE =
- Conservative: patient education and reassurance
- Epley manouvre: particle repositioning manoeuvres.
SECOND LINE =
- Prochlorperazine or Betahistine (vestibular suppressant medication)
- Vestibular rehabilitation exercises: Brandt-Daroff
THIRD LINE =
- Surgery: posterior canal occlusion preventing endolymphatic flow and stops vertigo

Question 9

Contraindications for epley manoeuvre

Answer 9

Neck injury
Carotid stenosis

Question 10

When to refer to ENT

Answer 10

• Persistent symptoms despite repeated repositioning procedures
• Symptoms and signs that have not resolved in 4 weeks
• Atypical symptoms or signs
• 3 or more periods of vertigo

Question 11

Complications

Answer 11

Falls in elderly patients