Benign paroxysmal positional vertigo: Difference between revisions

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==Background==
==Background==
*Abbreviation: BPPV
*Due to canalolithiasis (migration of otoconia into one of the semicircular canals)  
*Due to canalolithiasis (migration of otoconia into one of the semicircular canals)  
*Mean age is mid-50s; women are twice as likely to be affected as men
*Mean age is mid-50s; women are twice as likely to be affected as men
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==Clinical Features==
==Clinical Features==
*Sudden-onset vertigo and associated nystagmus precipitated by head movements
*Sudden-onset [[vertigo]] and associated [[nystagmus]] precipitated by head movements
**Latency period <30s between provocative head position and onset of nystagmus
**Latency period <30s between provocative head position and onset of nystagmus
**Intensity of nystagmus increases to a peak before slowly resolving
**Intensity of nystagmus increases to a peak before slowly resolving
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*[[Nausea/vomiting]] common
*[[Nausea/vomiting]] common
*Symptoms worse in the morning (symptoms fatigue as day goes on)
*Symptoms worse in the morning (symptoms fatigue as day goes on)
*No associated hearing loss or tinnitus
*No associated [[hearing loss]] or [[tinnitus]]
*MUST distinguish from central vertigo. See [[Vertigo#HINTS Exam|HINTS Exam]], See [[Stroke syndromes]], See [[Cerebellar stroke]]
*MUST distinguish from central vertigo ([[Vertigo#HINTS Exam|HINTS Exam]], [[Cerebellar stroke]])


==Differential Diagnosis==
==Differential Diagnosis==
{{Vertigo DDX}}
{{Vertigo DDX}}


==Diagnosis==
==Evaluation==
''See also [[vertigo]]''
''See [[vertigo]] for a general approach''


===Dix-Hallpike Maneuver===
===Dix-Hallpike Maneuver===
*50-85% Sensitive for BPPV<ref>Sacco RR et al. Management of Benign Paroxysmal Posi- tional Vertigo: A Randomized Controlled Trial. J Emerg Med. 2014 Apr;46(4):575-81</ref>
*''50-85% Sensitive for BPPV<ref>Sacco RR et al. Management of Benign Paroxysmal Posi- tional Vertigo: A Randomized Controlled Trial. J Emerg Med. 2014 Apr;46(4):575-81</ref>''
*Contraindications:<ref>Humphriss, Rachel; Baguley D; Sparks V; Peerman S; Mofat D (2003). "Contraindications to the Dix-Hallpike manoeuvre : a multidisciplinary review". International Journal of Audiology 42 (3): 166–173.</ref>
====Procedure====
*#Concern for [[Cervical Artery Dissection]]
*Patient sits upright
*#Cerebrovascular disease
*Patient's head is rotated to one side by 45 degrees. Then quickly lie the patient down
*#Concern for vertebrobasilar insufficiency, See [[Stroke syndromes]]
*Maintain the head in 45 degree rotation but also 20 degrees of extension off the end of the table.
*#Spinal injury
*Observe the eyes for 45 seconds for nystagmus. There is often 15 seconds of latency prior to symptoms.  
*#Cervical spondylosis
**Immediate symptoms requires consideration for central etiology
*'''A positive test for BPPV is evidenced by the rotational (torsional) nystagmus
**Fast phase of the rotatory nystagmus is toward the affected ear (geotropic nystagmus), which is the ear closest to the ground
**Rotational nystagmus away from affected ear (ageotropic nystagmus) requires consideration for central lesion


====Procedure====
====Contraindications<ref>Humphriss, Rachel; Baguley D; Sparks V; Peerman S; Mofat D (2003). "Contraindications to the Dix-Hallpike manoeuvre : a multidisciplinary review". International Journal of Audiology 42 (3): 166–173.</ref>====
#Patient sits upright
*Concern for [[Cervical Artery Dissection]]
#Patient's head is rotated to one side by 45 degrees. Then quickly lie the patient down
*[[CVA|Cerebrovascular disease]]
#Maintain the head in 45 degree rotation but also 20 degrees of extension off the end of the table.
*Concern for [[vertebrobasilar insufficiency]], See [[Stroke syndromes]]
#Observe the eyes for 45 seconds for nystagmus.  There is often 15 seconds of latency prior to symptoms.
*Spinal injury
#'''A positive test for BPPV is evidenced by the rotational nystagmus
*Cervical spondylosis
#*fast phase of the rotatory nystagmus is toward the affected ear, which is the ear closest to the ground


==Treatment==
==Management==
===Epley Maneuver<ref>Hilton, Malcolm P; Pinder, Darren K (2004). "The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo". In Hilton, Malcolm P. Cochrane Database of Systematic Reviews </ref>===
===Epley Maneuver<ref>Hilton, Malcolm P; Pinder, Darren K (2004). "The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo". In Hilton, Malcolm P. Cochrane Database of Systematic Reviews </ref>===
[[File:Epley.jpg|thumb|Eply manuver]]
[[File:Epley.jpg|thumb|Epley manuver]]
*Epley begins after the last step of the Dix Hallpike
*Epley begins after the last step of the Dix Hallpike
*Patient remains in the position with exacerbated nystagmus for approximately 1–2 minutes.
*Patient remains in the position with exacerbated nystagmus for approximately 1–2 minutes.
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*Keep the patient in the new position for 1 minute.
*Keep the patient in the new position for 1 minute.
*Finally bring the patient up to sitting while holding the head in 45 degree rotation.
*Finally bring the patient up to sitting while holding the head in 45 degree rotation.
*May require multiple attempts, but you can d/c pt home with daily exercises
*May require multiple attempts, but you can discharge patient home with daily exercises
**See link below for YouTube How-To videos
**Improvement after x1 in 47% of patients, after x2 an additional 16%, and after x3 an additional 21%<ref>Hughes D, Shakir A, Goggins S, et al. How many Epley manoeuvres are required to treat benign paroxysmal positional vertigo? J Laryngol Otol. 2015; 129(5):421-424.</ref>
**Home instruction: http://www.dizziness-and-balance.com/disorders/bppv/home/home-pc.html


===Medical management===
===Medical management===
*Antihistamines
*[[Antihistamines]]
**[[Diphenhydramine]] (Benadryl) 25-50mg IM/IV/PO q4hr
**[[Diphenhydramine]] (Benadryl) 25-50mg IM/IV/PO q4hr
**Meclizine (Antivert, Antrizine, Dramamine) 25mg PO QID
**[[Meclizine]](Antivert, Antrizine, Dramamine) 25mg PO QID
**Promethazine (Phenergan, Anergan, Prorex) 12.5-25mg PO/IM/IV q4-6hr
**[[Promethazine]](Phenergan, Anergan, Prorex) 12.5-25mg PO/IM/IV q4-6hr
*Anticholinergic
*[[Anticholinergic]]
**Scopolamine transdermal patch 0.5mg (behind ear) QID
**[[Scopolamine]] transdermal patch 0.5mg (behind ear) QID
*Benzodiazepines
*[[Benzodiazepines]]
**[[Lorazepam]] (Ativan), [[diazepam]] (Valium) or Klonopin (Clonazepam)
**[[Lorazepam]] (Ativan), [[diazepam]] (Valium) or Klonopin ([[clonazepam]])


==Disposition==
==Disposition==
*Refer pts w/ persistent symptoms to ENT
*Consider referral to ENT for persistent symptoms despite treatment


==See Also==
==See Also==
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==External Links==
==External Links==
*How to do Epley Manuever: http://www.youtube.com/watch?v=7ZgUx9G0uEs
*[http://www.youtube.com/watch?v=7ZgUx9G0uEs YouTube: How to do Epley Manuever]
*Dix-Hallpike and Epley Maneuvers for BPPV, in Claymation: http://www.youtube.com/watch?v=eOuzUi5ckrk
*[http://www.youtube.com/watch?v=eOuzUi5ckrk Dix-Hallpike and Epley Maneuvers for BPPV, in Claymation]
*[http://www.dizziness-and-balance.com/disorders/bppv/home/home-pc.html Home Treatments of Benign paroxysmal positional vertigo]


==References==
==References==
<references/>
<references/>
[[Category:ENT]]
[[Category:ENT]]
[[Category:Neuro]]
[[Category:Neurology]]
[[Category:Featured]]

Revision as of 20:31, 30 September 2019

Background

  • Abbreviation: BPPV
  • Due to canalolithiasis (migration of otoconia into one of the semicircular canals)
  • Mean age is mid-50s; women are twice as likely to be affected as men
  • Mean duration is 2 weeks

Clinical Features

  • Sudden-onset vertigo and associated nystagmus precipitated by head movements
    • Latency period <30s between provocative head position and onset of nystagmus
    • Intensity of nystagmus increases to a peak before slowly resolving
    • Duration of vertigo and nystagmus ranges from 5–40s
    • Repeated head positioning causes vertigo and nystagmus to fatigue and subside
    • Nystagmus reverses direction during the head down and head up portions of Dix-Hallpike
  • Nausea/vomiting common
  • Symptoms worse in the morning (symptoms fatigue as day goes on)
  • No associated hearing loss or tinnitus
  • MUST distinguish from central vertigo (HINTS Exam, Cerebellar stroke)

Differential Diagnosis

Vertigo

Evaluation

See vertigo for a general approach

Dix-Hallpike Maneuver

  • 50-85% Sensitive for BPPV[1]

Procedure

  • Patient sits upright
  • Patient's head is rotated to one side by 45 degrees. Then quickly lie the patient down
  • Maintain the head in 45 degree rotation but also 20 degrees of extension off the end of the table.
  • Observe the eyes for 45 seconds for nystagmus. There is often 15 seconds of latency prior to symptoms.
    • Immediate symptoms requires consideration for central etiology
  • A positive test for BPPV is evidenced by the rotational (torsional) nystagmus
    • Fast phase of the rotatory nystagmus is toward the affected ear (geotropic nystagmus), which is the ear closest to the ground
    • Rotational nystagmus away from affected ear (ageotropic nystagmus) requires consideration for central lesion

Contraindications[2]

Management

Epley Maneuver[3]

Epley manuver
  • Epley begins after the last step of the Dix Hallpike
  • Patient remains in the position with exacerbated nystagmus for approximately 1–2 minutes.
  • Patient's head is then turned 90 degrees to the opposite direction so that the unaffected ear faces the ground
    • Maintain the 20 degree neck extension
  • Keep the head and neck in a fixed position while the patient rolls onto their opposite shoulder. The patient is now looking downwards at a 45 degree angle.
  • Keep the patient in the new position for 1 minute.
  • Finally bring the patient up to sitting while holding the head in 45 degree rotation.
  • May require multiple attempts, but you can discharge patient home with daily exercises
    • Improvement after x1 in 47% of patients, after x2 an additional 16%, and after x3 an additional 21%[4]

Medical management

Disposition

  • Consider referral to ENT for persistent symptoms despite treatment

See Also

External Links

References

  1. Sacco RR et al. Management of Benign Paroxysmal Posi- tional Vertigo: A Randomized Controlled Trial. J Emerg Med. 2014 Apr;46(4):575-81
  2. Humphriss, Rachel; Baguley D; Sparks V; Peerman S; Mofat D (2003). "Contraindications to the Dix-Hallpike manoeuvre : a multidisciplinary review". International Journal of Audiology 42 (3): 166–173.
  3. Hilton, Malcolm P; Pinder, Darren K (2004). "The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo". In Hilton, Malcolm P. Cochrane Database of Systematic Reviews
  4. Hughes D, Shakir A, Goggins S, et al. How many Epley manoeuvres are required to treat benign paroxysmal positional vertigo? J Laryngol Otol. 2015; 129(5):421-424.