Benign Paroxysmal Positional Vertigo (BPPV)

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1. BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV) Sunil Kumar Daha

2. Introduction Most common cause of positional vertigo Women > Men D/t presence of otolithic debris from saccule or utricle affecting free flow of endolymph in semicircular canals ( cupulolithiasis ) Occurs secondary to free-floating canalith within posterior semicircular canal It may follow head injury but typically is spontaneous /idiopathic

3. Causes Idiopathic Infection (viral neuronitis ) Head trauma Surgical damage to the labyrinth Ischemic complication of Giant Cell Arteritis (GCA)

4. Clinical Features Sudden and distressing onset Recurrent episodes of vertigo lasting < 1 min Symptoms provoked by specific head movements Looking up while standing and sitting Lying down or getting up from bed Rolling over in bed Waxing and waning pattern of vertigo Sometimes associated nausea and vomiting No neurological symptoms

5. Pathophysiology Otoliths (CaCO3 particles) are normally attached to a membrane inside the utricle and saccule Utricle is connected to the semicircular ducts Otoliths may become displaced from the utricle to enter the posterior semicircular duct since this is the most dependent of the 3 ducts Changing head position relative to gravity causes the free otoliths to gravitate longitudinally through the canal Concurrent flow of endolymph stimulates the hair cells of the affected semicircular canal, causing vertigo

6. Variants of BPPV Posterior Canal BPPV ( most common!!) Anterior Canal BPPV Horizontal Canal BPPV Pure Torsional BPPV

7. Diagnosis Dix- Hallpike Maneuver: The Dix- Hallpike /Barany Maneuver, along with patient's history  diagnostic of BPPV

8. Cont… Investigations : generally not needed Electronystagmography (ENG): for detecting preexisting vestibular pathology Neuroimaging : If nystagmus doesn’t fit classical BPPV symptoms

9. Management Particle Repositioning Maneuver: Epley Maneuver ( choice of T/t ) Semont Maneuver Brandt- Daroff Exercise ( self home treatment ) Medications: Antiemetics Antihistaminics Anticholinergics Surgeries: ( better avoided d/t possibility of hearing loss ) Singular neurectomy Posterior Canal Plugging Procedure Vestibular Nerve Section

10. ( Epley maneuver) Epley Maneuver

11. Epley Maneuver Treatment of choice for BPPV The patient is positioned in a series of steps so as to slowly move the otoconia particles from the posterior semicircular canal back into the utricle Takes approximately 5 minutes The patient is instructed to wear a neck brace for 24 hours and to not bend down or lay flat for 24 hours after the procedure One week after the Maneuver, the Dix- Hallpike test is repeated If the patient does experience vertigo and nystagmus , then the maneuver is repeated with a vibrator placed on the skull in order to better dislodge the otoconia

12. Semont Maneuver

13. Brandt- Daroff Exercise

14. Surgical Singular neurectomy •Old procedure • Section the nerve that transmits information from the posterior semicircular canal ampulla toward the brain. •Can cause hearing loss in 7-17% of patients and fails in 8-12% Posterior Canal Plugging Procedure •The canal is gently, firmly packed off with tissue so the debris can no longer move within the canal and strike against the nerve endings •<20% hearing loss

15. Contd.. Vestibular Nerve Section •Done if medication fails •An incision is made behind the ear and balance-hearing nerve is located •The balance part of the nerve is cut •The success rate (no vertigo attacks) is over 90% •The hearing is usually not affected

16. References Uptodate 21.6 Kumar and Clark’s Clinical Medicine, 8 th Edition

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