This document discusses benign paroxysmal positional vertigo (BPPV). It begins with an overview of the anatomy and physiology of the vestibular system. It then defines BPPV and discusses its pathogenesis, symptoms, types, differential diagnosis, investigations and treatment modalities. The most common treatment is canalith repositioning procedures like the Epley maneuver which aims to move otoliths out of the semicircular canals.

1. Benign Paroxysmal Positional
Vertigo
1

2. Topic is covered under following heads
• Brief Anatomy and Physiology
• Introduction
• Aetio pathogenesis
• Symptoms
• Types and clinical features
• Differential diagnosis
• Investigations
• Treatment modalities
2

4. Anatomy of the vestibular system
5

5. Physiology
6

6. Benign Paroxysmal Positional Vertigo
(BPPV)
• Benign: not a very serious or progressive
condition
• Paroxysmal: sudden and unpredictable in onset
• Positional: comes with a change in head position
• Vertigo: causing a sense of dizziness.
7

7. Introduction
• BPPV – One of the commonest Vestibular
End organ disorders
• 17-25% of all vestibular disorders
• Most common aural cause of vertigo
• Chronic, Incapacitating, Affecting day to day
functioning
8

8. Introduction
• Hallmark of the disease is the onset of brief (seconds)
spells of often severe vertigo that are experienced
only with specific movements of the head with
respect to gravity.
• Typical Precipitating movements-
– Turning in bed,
– Getting In and Out of bed,
– Bending and straightening
– Extending the neck to look up and back
• “TOP SHELF VERTIGO”
9

9. History
• 1921 - First described by Barany
• 1952 - Dix-Hallpike reported this entity in a large number of
patients and described important features of nystagmus
• 1962, Dr Harold Schuknecht proposed the cupulolithiasis
(heavy cupula) theory.
• 1980, Brandt and Daroff proposed positional exercises based
on the canalolithiasis hypothesis even before the theory was
described
• 1980 – Hall, Ruby and McClure described the theory of
canalolithiasis
• 1991 - Free floating deposits demonstrated in Endolymph of
PSSC–Parnes, McClure 10

10. Benign positional vertigo -epidemiology
• Incidence: 1:20 in general practice
3:20 in ENT OPD
• U.S. study – incidence 64 per 100,000. Av 10-64 / lakh
• Incidence in general population is higher in persons older
than 40 years.
• Elderly patients – incidence approximately 8%.
• 20% of all falls that result in hospitalization for serious
injuries in the elderly are due to vertigo of end-organ origin
(most often related to BPPV).
• Average age of onset 51 years. M=F, some studies show a
slight predilection for women.
• Rarely seen in persons younger than 35 years without a
history of antecedent head trauma.
11

11. • Idiopathic – 48%
• Head trauma
• Viral neuronitis
• Middle ear infection
• Surgical damage to the labyrinth
• Prolonged bed rest
12
BPPV- AETIOLOGY

12. PATHOPHYSIOLOGY
OF BPPV
• Vertigo originates in Posterior
Semi circular canal in majority
of cases
• Rarely in Lateral Semi circular
Canal and still rarer in Superior
semi circular Canal
• “Cupulolithiasis” – Schucknect
• “Canalithiasis” –Hal, Ruby,
McClure, Parnes, Epley
• Free Floating particles in
endolymph of Posterior Semi
circular Canal
13

13. Theories of BPPV
14
Cupulolithiasis
• In 1962, Dr Harold Schuknecht proposed the cupulolithiasis
(heavy cupula) theory.
• Discovered basophilic particles or densities that were
adherent to the cupula.
• He postulated that the PSC was rendered sensitive to gravity
by these abnormal dense particles attached to, or impinging
on, the cupula.
• This produces persistent nystagmus and also explains the
dizziness when a patient tilts the head backward.
• Cupulolithiasis – possible role in atypical BPPV

14. Theories of BPPV
 Canalolithiasis :
– Hall, Ruby and McClure – 1980
– Free floating deposits demonstrated in Endolymph of PSSC–Parnes,
McClure-1991
• The most widely accepted theory of the pathophysiology of BPV
• Otoliths (calcium carbonate particles) are normally attached to a membrane
inside the utricle and saccule
• Otoliths may become displaced from the utricle to enter the posterior
semicircular duct since this is the most dependent of the 3 ducts
• Changing head position relative to gravity causes the free Otoliths to
gravitate longitudinally through the canal.
• The concurrent flow of endolymph stimulates the hair cells of the affected
semicircular canal, causing vertigo.
• Explains all features of typical nystagmus
15

15. Canalolithiasis
16

16. Symptoms
• Discrete episodes of vertigo induced by specific head
motions of duration less than 1 min.
• Single bouts clustered in time with remissions lasting
months or more.
• Dizziness with rapid head movements. (Cupulolithiasis)
• Disequilibrium worse in the morning or after day time
naps.
• Nausea and vomiting
17

17. NYSTAGMUS IN BPPV …
• Nystagmus : characterization and types
– Rt / Lt , vertical / horizontal , changing
– Tortional = Rotational – clockwise /
counterclockwise
– Geotropic- toward the earth
– Ageotropic – opposite

18. DIRECTION OF NYSTAGMUS
Destructive lesion of the vestibular end organ or the vestibular nerve will
produce transient horizontal nystagmus with its quicker phase towards the
opposite side.
Unilateral cerebellar lesion will produce vertigo with its quicker phase to the
same side
Paretic lesion of labyrinth the nystagmus is towards healthy side
19

19. Nystagmus
20
Appearance Latency Duration Fatigability Localisation
Central Pure vertical,
usually downbeat
Unusual Persistent Unusual Brainstem or
cerebellum
Peripheral
Postr SCC
Torsional towards
the downward
eye, vertical
upbeat, geotropic
Usual
(seconds)
Brief(<1
min)
Usual Posterior semi-
circular canal
Peripheral
Lat SCC
Horizontal,
geotropic or
ageotropic
Usual
(seconds)
Brief (<1
min)
Less
susceptible
than PSCC
Horizontal semi-
circular canal

20. I. Classic BPPV
• Involves the Posterior SCC
– Canalilithiasis of Posterior SCC – most frequent
cause
– Reversal upon return to upright position
– Response decline upon repetitive provocation
Types of BPPV

21. II. Lat. SCC BPPV
• Most common atypical BPPV
• 3-9% of cases
• Paroxysmal horizontal direction changing nystagmus –beats
towards ground (geotropic) when head turned to side while
patient lies supine - Canalilithiasis
• Ageotropic – Nystagmus away from the dependent affected
ear - Cupulolithiasis
• Nystagmus lasts 1 minute, minimal latency and no fatigability.
• Occurs with head to either side but stronger on one side.
22

22. III. Ant. SCC BPPV
• Rare – 2%
• Down-beating /torsional NG for the opposite ear
on Dix-Hallpike maneuver
• Torsional downbeating nystagmus during
Hallpike test induced when the abnormal
anterior canal (which lies at right angles to
posterior) is uppermost.
• Repositioning maneuver starts with abnormal ear
uppermost moving across to opposite head
hanging position.
24

23. BPPV - D.D
• Meniere’s disease
• Vestibular migraine
• Recurrent vestibulopathy
• Vestibular Labyrinthitis – Lasting days
• Inner ear fistula
• Inner ear trauma
• Superior SCC dehiscence syndrome
• Central origin : Stroke , MS , cerebellar degeneration
• Vertebral artery insufficiency
• Cervical vertigo
25
Minutes to hours
Variable duration

24. HISTORY:
Confirmation of dizziness
Associated symptoms
•Otalgia, otorrhoea, Tinnitus, headache,
•Aural fullness, head injury, acoustic
trauma, ototoxic drug intake, DM, HTN,
•TB, CVA, IHD
•H/o Ear surgery
•Difficulty in speaking/walking
•Diplopia/dysarthria, loss of consciousness
points to brain stem dysfunction
26
EVALUATION AND DIAGNOSIS

25. Pattern Of Vertigo
Onset, duration, continuous/ paroxysmal
Period of complete relief
Postural
Preliminary tests Of Balance
Degree Of Vertigo – Is there nausea/vomiting
(I) Finger Pointing
(II) Rapid Alternate Movements Of Hand
(III)Gait
(IV)Tandem Walk
(V) Rhombergs test
(VI)Unterbergers test
27

26. Ears-EAC-FB/WAX
-TM for perforation, AOM/OME
-Cholesteatoma
Hearing tests
-TFT
-PTA
-FFH
-Impedance Audiometry
Otological examination
Detailed clinical examination
General
Systemic
28

27.  Ocular Examination
Ptosis
Pupillary reactivity
Ocular alignment
Eye movements
Convergence
29

28. Labyrinthine Function tests
(I) Caloric tests to look for nystagmus
(II) Dix Hallpike tests for positional vertigo
(III) ENG
(IV) VNG
DIX-HALL PIKE TESTS
30

29. RECENT ADVANCES IN EVALUATION
VIDEO NYSTAGMOGRAPHY (VNG)
•VNG– Video images of the eyes are obtained without
direct contact using high resolution cameras with infrared
illumination.
Setup is fast & as easy using Frenzel glasses.
The eyes are visualized, enabling simultaneous subjective
evaluation while eye movements are analyzed by digital
image processing to obtain vertical and horizontal eye
position.
Can be used for teaching purpose.
31

30. The Dix-Hallpike test
33

31. Laboratory tests
Routine hemogram, urine examination
Blood sugar
T3, T4 ,TSH
Serological tests to rule out Syphilis
Radiological investigations
X-Ray Skull-Per orbital view
X-Ray mastoids
X-Ray Cervical spine
CT- Temporal bone and Brain
SPECIAL TESTS
EEG
BERA
Psychological Evaluation
34
To rule out other pathologies

32. BPPV - Treatment
• Watchful waiting
• Pharmacotherapy
• Canalith repositioning procedure
• Vestibular rehabilitation
• Surgery care
– Singular neurectomy
– Post. Canal occlusion
– Vestibular nerve section

33. Pharmacotherapy
• Directed principally at suppressing vestibular
response.
• Alleviating nausea associated with vertigo.
• Does not treat underlying cause.
– Low dose diazepam – used prior to CRP
– Antiemetics like phenergan
– Longer acting vestibular suppressants like
clonazepam for chronic disequilibrium
36

34. Canalith Repositioning Procedure ( CRP )
• The treatment of choice for BPPV (Epley maneuver)
• The patient positioned in a series of steps so as to slowly move the
otoconia particles from the Posterior SCC into the utricle.
• Takes approximately 5 minutes.
• The patient is instructed to wear a neck brace for 24 hours and to
not bend down or lay flat for 24 hours after the procedure.
• Dix-Hallpike test is repeated soon after the CRP and after 1 week.
• If the patient does experience vertigo and nystagmus, then the
CRP is repeated with a vibrator placed on the skull in order to
dislodge the otoconia.
37

35. The Epley Maneuver
38

36. Epley manouevre
39

37. 40

38. 41

39. 42

40. 43

41. 44

42. CRP – Semont maneuver
45

43. Brandt-Daroff Exercises
• Method of treating BPPV, usually used when the
office treatment fails.
• These exercises should be performed
– For one week, three times per day
– For three weeks, twice per day.
• In each time, one performs the maneuver as shown
five times.
• 1 repetition = maneuver done to each side in turn
(takes 2 minutes)
46

44. Brandt-Daroff Exercises
47

45. Lampert maneuver- Lat. SCC BPPV
48

46. Complications of CRP
• Failure – 25% (12%-56)
• Recurrence – 13% in 6 months
• Side effects
– Nausea ,Vomiting, Fainting, Sweating
• Worse vertigo – Lateral SCC BPPV
• “Canalith jam”
• Conversion to another canal
49

47. Vestibular Rehabilitation Exercises (VRE)
• Reduces symptoms, Promotes Spontaneous
resolution
• Safe and effective
• Cawthorne-Cooksey Exercises
• Need to be carried out regularly
– Over 12-16 Weeks before improvement is noticed
50

48. Vestibular rehabilitaions
51

49. Surgery
• Singular neurectomy
• Posterior Canal Plugging Procedure
• Vestibular Nerve Section
52
Role of Surgery
• Very limited, < 2% may need Surgery which is rarely offered
• Highly responsive to physical therapy interventions
• Only in intractable cases affecting the life style of the patient

50. Singular neurectomy
• Evolved by Gacek
• Section the posterior ampullary nerve that transmits
information from the posterior semicircular canal
ampulla toward the brain.
• Highly rational
• Technically difficult
• Can cause hearing loss in 7-17% of patients and fails
in 8-12%.
• Anatomical abnormalities of singular canal
53

51. Singular neurectomy
54

52. Posterior Canal Plugging Procedure
• Parnes and McLure introduced this concept.
• Prevent movement of debris towards ampulla.
• Technically simpler and safer.
• Replaced the singular neurectomy.
• Less than 20% hearing loss.
55

53. Posterior Canal Plugging Procedure
56

54. Vestibular Nerve Section
• Done when the attacks of vertigo cannot be controlled
with medication. Seems unreasonably aggressive for
BPPV
• Approaches – Middle fossa, retrolabyrinthine,
retrosigmoid
• The vestibular part of the nerve is cut.
• The operation is done with a neurosurgeon and takes
about two hours.
• The success rate (no vertigo attacks) is over 90%.
• The hearing is slightly affected.
57

55. Vestibular Nerve Section
58

56. Bibliography
• Scott Brown Otorhinolaryngology, Head and Neck
surgery, 7th
edition
• Otorhinolaryngology Head & Neck Surgery,
Ballenger (17th
edition)
• Galsscock – Shambaugh Surgery of the Ear 5th
edition
• Cumming’s otolaryngology, head and neck surgery
4th
edition
59

57. • Thank you
60