2A. Benign positional paroxysmal vertigo

Benign positional paroxysmal vertigo (BPPV) is a cause of recurring vertigo which occurs due to canalolithiasis, stones in the semicircular canals of the inner ear.

The peak incidence is in the 50s and it affects females more often.

There are two types, posterior canal BPPV (90% of cases) and horisontal canal BPPV (10%).

Clinical features

BPPV causes paroxysmal positional harmonic vestibular signs. Paroxysmal and positional meaning that the symptoms occur in suddenly in certain head positions. The symptoms include vertigo and nystagmus, and last less than 1 minute. In between these episodes, the patient is asymptomatic.

Diagnosis and evaluation

Diagnosis of posterior canal BPPV is based on the Dix-Hallpike test:

• Procedure:
  • Patient sits on the examination table
  • Rotate the head 45 degrees to the side of the suspected BPPV
  • Keeping the neck rotated, quickly lay the patient in a supine position so that their head hangs slightly off the short end of the table
  • Hold this position for 20 seconds
  • Slowly reposition patient into the original seated position
• Negative:
  • Patient experiences no vertigo
  • No nystagmus appears
• Positive:
  • Patient experiences vertigo and nystagmus when supine, which spontaneously resolve within the 20 seconds

Diagnosis of horizontal canal BPPV is based on the supine roll test.

Treatment

Posterior canal BPPV is treated by the Epley repositioning manoeuvre. It moves the stone into the utricle and out of the semicircular canal. The manoueuvre may need to be repeated multiple times, and the patient may be taught the manoeuvre for performance at home.

• Procedure:
  • Patient sits on the examination table
  • Rotate the head 45 degrees to the side of the suspected BPPV
  • Keeping the neck rotated, quickly lay the patient in a supine position so that their head hangs slightly off the short end of the table
  • Hold this position for 30 seconds, or until the nystagmus disappears
  • Turn patient’s head by 90° towards the unaffected side
  • Hold this position for 30 seconds, or until the nystagmus disappears
  • Turn patient’s head another 90° towards the unaffected side, so that the patient is lying on their side with they head facing the ground
  • Hold this position for 30 seconds, or until the nystagmus disappears
  • Slowly bring patient back to a seated, upright position with the head in a neutral position
  • Ask patient to remain in this position for about 15 minutes

Horisontal canal BPPV is treated by the barbecue manoeuvre.