Benign Paroxysomal Positional Vertigo
Pathogenesis |
BPPV is the most common cause of peripheral vertigo, typically caused by a mechanical labyrinth disorder. Free floating otoconial debris get lodged in semicircular canals (canalolithiasis), or in the ampullary cupula (cupulolithiasis). The most common cause of BPPV is idiopathic, or primary BPPV, comprising 50-70% of cases. Primary is referring to the numerous degenerative aging changes since this condition mainly targets the elderly population. Secondary BPPV, the remaining 30-50%, is caused by head trauma. The most common canal that is involved is the posterior canal, followed by lateral and anterior, respectively.
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Clinical Presentation |
Lateral semicircular canal (LSC): Dizziness, sleep disorder, concentration problems, & decreased appetite. These symptoms are more intense compared to posterior canal symptoms. Patients usually feel the first attack at night when they turn sideways while sleeping, waking the patient with symptoms lasting 30-60 seconds, sometimes longer. Nystagmus can also be observed in the upright position in patients suffering from LSC BPPV.
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Examination |
To confirm LSC involvement, the horizontal roll test it used. To perform the test, have the patient lay supine on a table. Next, make sure the head is inclined 30 degrees from the horizontal plane. Rotate the head 60 degrees to each side, hold, observe for nystagmus.
To confirm PSC involvement, the Dix-Hallpike maneuver is performed. With the patient sitting, rotate the head 45 degrees to one side. Maintaining this position, lie the patient down rapidly, extending the neck 30 degrees below the horizontal plane while in supine; check for nystagmus. Nystagmus will usually occur on the involved side. |
Treatment |
Lateral SC: Lempert roll maneuver
Start with the patient supine, head rotated 45 degrees to the involved side, hold 10-30 seconds. Next, rotate the head 90 degrees towards the uninvolved side, hold 10-30 seconds. Again, rotate 90 degrees towards the uninvolved so they are now prone, facing down. Hold 10-30 seconds. Rotate 90 degrees to the uninvolved side, patient is now sideline, hold 10-30 seconds. Now, the patient prepares to be seated upright by moving from a sideline position to supine position, and quickly comes into a seated position. Posterior SC: Epley maneuver Similar to the Dix-Hallpike maneuver, Epley's maneuver starts with the patient seated long sitting, head rotated 45 degrees towards the affected side. Next, the patient lie's down supine, with the head 30 degrees below the horizontal plane. Hold 30 seconds. While maintaining this position, rotate the head 90 degrees towards the other side, hold 30 seconds. Next, rotate head 90 degrees again so the patient is sideline, with their head angled down 45 degrees, hold 30 seconds. The last part consists of helping the patient to an upright seated position. After treatment, patient is instructed not to bend over, lie back, or tilt head for the next 2 days. Also, the patient is educated about sleeping positions; sleep with the head slightly elevated & avoid turning while sleeping toward the affected side. |