II. Epidemiology

  1. Most common in ages 50 to 70 years old

III. Causes

  1. Idiopathic in >50% of older patients
  2. Ear Trauma may precipitate (esp. younger patients with BPPV)

IV. Pathophysiology

  1. Temporary displacement of otolith (otoconia, canaliths)
    1. Displaced onto gelatinous capsule
    2. Typically canaliths dislodged from vestibule into the posterior semicircular canal
  2. Symptoms persist until otolith (loose bodies) resorbed or repositioned into vestibule

V. Symptoms

  1. Severity
    1. Severe episodic Vertigo
  2. Provocative
    1. Only change of head position triggers Vertigo
    2. Provoked by turning onto one side (not the other)
    3. Vertigo with vertical head movements
      1. Provoked by extending neck while looking up
    4. Recurs with similar movement
      1. However, exhibits fatigability (effect diminishes with consecutive provocative maneuvers)
    5. Asymptomatic at rest
  3. Palliative
    1. Visual Fixation
  4. Duration
    1. Environment spins for 10-20 seconds (max of 60 seconds), then resolves
  5. Timing
    1. Symptom onset is delayed for seconds after the precipitating head movement (latency)
    2. Occurs at night while recumbent

VI. Signs

  1. Dix-Hallpike Maneuver elicits symptoms
  2. Rotary Nystagmus accompanies Vertigo sensation

VII. Precautions: Neurologic Red Flags suggestive of alternative diagnosis

  1. Dysarthria
  2. Diplopia
  3. Dysmetria
  4. Dysphagia
  5. Dysdiadochokinesia (DDK)
    1. Inability to perform rapid, alternating movements

VIII. Differential Diagnosis

  1. See Vertigo Causes
  2. Diagnosis of exclusion
    1. Rule out CNS and Ear organic disease
      1. BPPV is a Triggered Vestibular Syndrome and should not persist without provocation
      2. Acute Vestibular Syndrome (constant Vertigo), especially with positive HiNTs Exam is CVA until proven otherwise
    2. No Neurologic Red Flags (see above)
    3. Vertigo is classic for BPPV (see symptoms and signs above)
      1. Head movement consistently produces severe, brief Vertigo with rotary Nystagmus
        1. Dix-Hallpike Maneuver positive
        2. Contrast with Vestibular Neuritis which persists regardless of provocation
      2. Vertigo lasts <60 seconds, and exhibits latency and fatigability
      3. Visual Fixation and avoiding head movement are palliative

IX. Management

  1. See Vertigo Management
    1. Primary management is with Canalith Repositioning, not medications
    2. Exercise caution with medications due to risk of falls, and circumventing central compensation
  2. Canalith Repositioning Procedure (Epley Maneuver)
    1. As effective as medication therapy and recommended as part of acute medical care (including ED care)
    2. Successful in 70% of first trials (approaches 100% on further attempts)
    3. Hilton (2014) Cochrane Database Syst Rev (12):CD003162 [PubMed]
    4. Sacco (2014) J Emerg Med 46(4): 575-81 [PubMed]
  3. Brandt-Daroff Exercises
    1. Repositioning maneuvers performed by patient at home
      1. Mechanism may be to habituate to Vertigo rather than return canaliths to vestibule (Epley is preferred)
    2. https://www.youtube.com/watch?v=CTZfIv165sY
    3. http://www.ncuh.nhs.uk/our-services/brandt-daroff-excercises-quick-guide.pdf

X. Course

  1. Self limited
  2. Symptoms resolve in 4-6 weeks
  3. Prolonged disabling symptoms in 33% of patients

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Ontology: Benign Paroxysmal Positional Vertigo (C0155502)

Definition (MSH) Idiopathic recurrent VERTIGO associated with POSITIONAL NYSTAGMUS. It is associated with a vestibular loss without other neurological or auditory signs. Unlike in LABYRINTHITIS and VESTIBULAR NEURONITIS inflammation in the ear is not observed.
Concepts Disease or Syndrome (T047)
MSH C562859 , D065635
ICD9 386.11
SnomedCT 267763004, 111541001, 232285008
English BPPV - Ben parox posit vertigo, Benign parox positionl vertigo, VERTIGO, BENIGN PAROXYSMAL POSITIONAL, benign paroxysmal positional nystagmus (diagnosis), benign paroxysmal positional vertigo, benign paroxysmal positional vertigo (diagnosis), benign paroxysmal positional nystagmus, Benign positional vertigo, Benign parxysmal vertigo, BPPV (benign paroxysmal positional vertigo), VERTIGO, BENIGN RECURRENT, BRV, VESTIBULOPATHY, FAMILIAL, benign positional vertigo, positional vertigo benign, Vertigo;benign positional, vertigo benign positional, positional benign vertigo, Vertigo, Benign Recurrent, Vertigo, benign positional, BPPV, Benign paroxysmal postural vertigo, Vestibulopathy, Familial, Familial Vestibulopathy, Familial Vestibulopathies, Vertigo, Benign Paroxysmal Positional, Benign Recurrent Vertigos, Familial Benign Recurrent Vertigo, Benign Paroxysmal Positional Vertigo, Recurrent Vertigo, Benign, Recurrent Vertigos, Benign, Vertigos, Benign Recurrent, Vestibulopathies, Familial, Benign Recurrent Vertigo, Benign paroxysmal positional vertigo, Benign paroxysmal positional nystagmus, BPPV - Benign paroxysmal positional vertigo, Benign recurrent vertigo, Benign paroxysmal positional vertigo (disorder), Benign recurrent vertigo (disorder)
Dutch BPPV, benigne paroxysmale houdingsafhankelijke draaiduizeligheid, benigne paroxysmale positionele draaiduizeligheid, benigne positionele draaiduizeligheid
French VPPB (Vertige paroxystique positionnel bénin), Vertige positionnel bénin, Vertige positionnel paroxystique bénin, Vertige paroxystique positionnel bénin
German gutartiger paroxysmaler Lagerungsschwindel, BPPV, gutartiger Lagerungsschwindel
Italian Vertigine posturale parossistica benigna, Vertigine posturale benigna
Portuguese Vertigem paroxística benigna de posição, Vertigem benigna de posição, Vertigem ortostática paroxística benigna
Spanish Vértigo posicional paroxístico benigno (BPPV), Vértigo posicional paroxístico benigno, Vértigo paroxístico posicional benigno, Vértigo postural benigno, nistagmo posicional paroxístico benigno, vértigo posicional paroxístico benigno (trastorno), vértigo posicional paroxístico benigno, vértigo recurrente benigno (trastorno), vértigo recurrente benigno
Japanese 良性発作性体位性回転性めまい, 良性発作性頭位性回転性めまい, 良性頭位性回転性めまい, BPPV, リョウセイトウイセイカイテンセイメマイ, リョウセイホッサセイトウイセイカイテンセイメマイ, リョウセイホッサセイタイイセイカイテンセイメマイ, BPPV
Czech Benigní paroxysmální polohové vertigo, Benigní polohové vertigo, BPPV
Hungarian BPPV, Benignus paroxysmalis positionalis vertigo, Benignus positionalis vertigo