Benign Paroxysmal Positional Vertigo (BPPV)

• Vertigo: Perception of motion in the absence of motion; described as swaying, tilting, spinning, or feeling unbalanced.
• Dizziness: An imprecise term often used to describe vertigo, leading to confusion in diagnosis.
• BPPV: The most common cause of peripheral vertigo, accounting for over half of all cases.

Introduction

• Vertigo: Sensation of motion without movement, commonly leading to over three million emergency department visits annually.
• BPPV: Accounts for 20% of vertigo cases; often misdiagnosed.
• Historical Background: First described by Barany in 1921, further detailed by Dix and Hallpike in 1952.

Etiology

• Cause: Displacement of otoconia within semicircular canals.
• Primary BPPV: Idiopathic, accounting for 50-70% of cases.
• Secondary BPPV: Linked to head trauma, vestibular neuronitis, labyrinthitis, Ménière disease, migraine, ischemia, and iatrogenic causes.

Epidemiology

• Peak Incidence: Ages 50-70.
• Incidence in the US: 64 per 100,000 annually; incidence increases by 38% each decade.
• Prevalence: Higher in women (3.2%) than men (1.6%).

Pathophysiology

• Semicircular Canals: Three per ear, oriented perpendicularly to detect head movements.
• Cupulolithiasis: Otoconia adhere to the cupula, making it heavy and causing persistent nystagmus.
• Canalithiasis: Free-moving otoconia in the semicircular canal cause symptoms when the head moves.

History and Physical

• History: Detailed history is crucial to differentiate between vestibular and central causes.
  • Symptoms: Vertigo triggered by head movement, brief episodes, nausea, vomiting.
  • Triggers: Sudden movement from erect to supine position, with head at 45-degree angle.
  • Duration: Symptoms typically last 20-30 seconds.
• Physical Examination:
  • Dix-Hallpike Maneuver: Diagnostic test to provoke symptoms and observe nystagmus.
  • Other Tests: Supine lateral head test for lateral/horizontal canal BPPV.

Evaluation

• Dix-Hallpike Test: Pathognomonic for BPPV, no need for laboratory tests.
• Imaging: CT/MRI to rule out other causes of vertigo.
• Supine Lateral Head Test: Diagnoses lateral/horizontal canal BPPV.

Treatment/Management

• Patient Education: Explaining BPPV and its management.
• Repositioning Maneuvers:
  • Epley Maneuver: Standard treatment for posterior canal BPPV.
  • Semont Maneuver: Alternative repositioning maneuver.
  • Contraindications: Severe cervical disease, vertebrobasilar disease, unstable cardiovascular disease.
• Medications: Generally ineffective; antihistamines (e.g., meclizine) and anti-emetics (e.g., ondansetron) for symptom relief.
• Brandt-Daroff exercises

Repositioning Maneuvers

• Epley Maneuver Steps:
  1. Start sitting with head turned toward the affected side.
  2. Recline to supine position with head turned 45 degrees to the affected side.
  3. Hold for 30 seconds until nystagmus stops.
  4. Turn head 45 degrees to the opposite side and hold.
  5. Roll to the opposite side with head turned downward.
  6. Sit up slowly with head still turned.

Surgical Treatment

• Indication: Reserved for refractory cases.
• Options:
  • Singular Neurectomy: Severing the singular nerve.
  • Posterior Canal Occlusion: Blocking the affected canal.

Differential Diagnosis

• Ménière disease
• Inner ear concussion
• Alcohol intoxication
• Labyrinthitis/vestibular neuronitis
• Vascular loop syndrome
• Central positional nystagmus
• Acoustic neuroma/meningioma
• Vertebral artery insufficiency
• Orthostatic hypotension

Prognosis

• Remission: One-third at three weeks, majority at six months.
• Recurrence: 15-50% within 40 months, 18% over ten years.

Complications

• Persistent nausea and vomiting.
• Risk of accidents due to sudden vertigo episodes.

Deterrence and Patient Education

• Follow-up: Recommended within one to four weeks post-treatment.
• Reassurance: BPPV is non-life-threatening and manageable.
• Recurrence: Common, may need further treatment.

Enhancing Healthcare Team Outcomes

• Awareness: Crucial for primary care physicians, nurse practitioners, urgent care providers, and emergency clinicians.
• Management: Proper diagnosis and treatment improve prognosis, though recurrence is common, especially in females, older patients, and those with psychiatric comorbidities.