Benign Paroxysmal Positional Vertigo - Departmental Seminar by Dr. Shriyash Sinha

1. BENIGN PAROXYSMAL
POSITIONAL VERTIGO
SHRIYASH SINHA
1st Year PGT
Dept of ENT
Calcutta National Medical College

2. • First described by Barany in 1921.
• The term BPPV was coined by Dix and Hallpike. In 1952, they
described the provoking maneuvers.
• BENIGN PAROXYSMAL POSITIONAL VERTIGO

3. Why study about BPPV?
• BPPV is the commonest presenting cause of vertigo.
• Lifetime prevalence from 2.4% to 9%.
• Treatment can be performed in the clinic with a good outcome,
making it the most rewarding vestibular condition to manage.

4. ANATOMY AND PHYSIOLOGY OF THE INNER
EAR

5. PATHOPHYSIOLOGY
• Otoconia are calcium carbonate crystals embedded in the macula of
the utricle and saccule.
• They have a greater density than the surrounding endolymph, thus
making the macula sensitive to changes in linear acceleration and
importantly, gravity.
• What happens to the otoconia in BPPV?

6. • TWO THEORIES
• 1. Theory of Cupulolithiasis
• 2. Theory of Canalolithiasis
• Latency
• Fatiguability

7. SYMPTOMS AND NATURAL COURSE OF THE
DISEASE
• M/C arises from the posterior SCC.
• p SCC 93%
• h SCC 5%
• a SCC 2%
1. Size of the common crus of the posterior SCC
2. Position below the utricle when supine
3. Dependent position when both supine and erect

8. • Hallmark of BPPV is vertigo lasting seconds with or without nausea,
and imbalance on lying down, sitting up from the lying position, or
rolling in bed and when extending or flexing the neck.
• These symptoms can present in clusters with several attacks per day.
• In between attacks, or shortly after successful treatment, patients are
either symptom free or have a sense of imbalance as if ‘walking on
pillows’.

9. • BPPV is recurrent in 12.5% of the cases and is persistent in 10% of the
cases. (Choi et al)

10. ETIOLOGY
• Most commonly primary or idiopathic (especially in old age)
• May be associated with other pathologies:
• Vestibular Neuritis
• Otosclerosis, following stapedectomy
• Meniere’s Disease
• Head trauma, traumatic spinal cord injuries
• Migrainous Vertigo
• Cochlear or vestibular failure
• Vertebrobasilar ischaemia

11. DIAGNOSIS
• On the basis of typical signs (nystagmus) and symptoms (vertigo and
nausea) provoked by specific positional tests.
• Vestibular eye movements are based on Ewald’s Principles
• The direction of eye movement is in the plane of the canal(s) that are
stimulated.
• In the horizontal canal, endolymph flow towards the ampulla (ampullopetal)
results in an excitatory and stronger response than the ampullofugal flow,
which is inhibitory. The opposite holds true for the vertical canals.

12. • Right Dix Hallpike test stimulates the Left Anterior and the Right
Posterior canals.
• Right Dix Hallpike : LARP
• Left Dix Hallpike : RALP
• Direction of the nystagmus will help us determine which canal is
involved.

14. TREATMENT OF P-BPPV
• REPOSITIONING MANUEVERS
• 1. Epleys Repositioning Manoeuvre or Canalith Repositioning
Manoeuvre (CRM)
CRM on its own is effective in close to 80% of the cases.

16. 2. Semont’s Liberatory Manouevre

17. • Advantages and Disadvantages of Semont’s Manouevre.

18. 3. BRANDT DAROFF POSITIONAL EXERCISES
• Consists of a rapid sequence of lateral head / body tilts.
• Starting from the sitting position, the patient rapidly moves to the
challenging position, ie, lying on the affected side (nose 45 degrees
up) and remains in this position for atleast 30 seconds or until the
vertigo subsides. The patient then sits up for 30 seconds and
thereafter assumes the opposite head lateral and nose-up position
for 30 seconds before siting up.
• This is repeated for 15 minutes three times daily.

19. Factors affecting the outcomes
• Patients with BPPV due to head trauma tend to improve less with
treatment than idiopathic BPPV patients, while patients with previous
Vestibular Neuronitis seem to have a better prognosis than patients
with BPPV due to other etiologies.

20. • Imaging of the posterior fossa, to rule out central pathology causing
vertigo is needed when:
• 1. Nystagmus is atypical for any of the BPPV syndromes
• 2. Brainstem or cerebellar signs are present
• 3. Positional vertigo does not resolve with repeated therapeutic maneuvers.

21. COMPLICATIONS AND ADVERSE REACTIONS
• Gait instability
• Conversion of p BPPV to a BPPV or h BPPV in about 6% of treated
patients.
• Neck strain

22. SURGICAL TREATMENT OF BPPV
• 1. p SCC occlusion surgery
• 2. Singular neurectomy via transcanal approach

23. h BPPV TREATMENT
• 1. Forced prolonged position on the healthy side.
• 2. 270 degree Barbeque Manouevre
• 3. 360 degree Yaw rotation
• 4. Gufoni Liberatory Manouevre

24. THANK YOU
REFERENCES: Scott Brown’s Otorhinolaryngology Head & Neck Surgery
Volume 2, Eighth Edition