1. Benign paroxysmal positioning
vertigo(sbo-3)
Definition:
Benign paroxysmal positioning vertigo is a disorder characterized by brief attacks of vertigo ,with
associated with nystagmus,precipitated by certain changes in head position with respect to gravity.It
is the most common cause of the syndrome of provoked vertigo.
Aetiology ;
Otoconia are crystal of calcium carbonate that are normally found embedded in the gelatinous
otolithic membranes of the utricle &saccule. If free floating otoconia find their way into the duct of
an SSC (canalolithiasis) or cupula of an SSC(cupulolithiasis).
In cases where the otoconia are in the posterior or anterior (superior) SSC ,the nystagmus will be
vertical torsional.In constrast,the nystagmus will be horizontal in cases where the otoconia are in the
lateral SSC.
BPPV may occur as a complication of head trauma or vestibular neuritis.Symptoms usually begin
wthin days following the head trauma .They may not appear for weeks or even years after an
episode of vestibular neuritis.Progressive inner ear disease (Meniere’s disease, cogan’s syndrome).
In most cases ,no cause is identified.
Epidemiology
Women are more frequently affected than are men.BPPV can occur all age group but most common
in elderly . The majority of the patients have posterior SSC BPPV,while about 15% have the lateral
SSC variant.The superior SSC variant is rare.
Clinical manifestation
The most provocative manoeuvre include rolling over in bed,getting in &out of bed. While tying
shoelaces, while looking up.Each episode vertigo typically lasts 10-20seconds.
The characteristic clinical sign of BPPV is nystagmus following a Dix- Hallpike manoeuvre.The patient
is seated on a Bed/the patient head ‘s is turned to the left &quickly pitch backwards until the head is
hanging over end of the bed ,the clinician observe a latent period of several seconds,vertical-torsional
nystagmus nystagmus last for less than 30seconds. The test can be repeated with head
turned to the right &then again in straight head hanging position.
Posterior SSC variant BPPV; nystagmus will be upbeating.
Lateral SSC variant BPPv;nystagmus will be horizontal.

2. Diagnosis
BPPV is a clinical diagnosis.
Most patients with BPPV will have no abnormalities on vestibular & auditory functions test.
MRI required to exclude central cause for their presentation.
Management options;
BPPV can be effectively treated by relocating otoconia from the SSC duct into vestibule using the
Epley manoeuvre which is contraindicated in patients with severe neck disease& high grade carotid
stenosis.
Advise following Epleys manoeuvre; The patient should remain instructed to remain upright for 24
hrs after treatment & to avoid sleep on the affected side for the following weeks.
Repeat treatment may improve the remission rate. (patient can learn to treat themselves.)
In cases of BPPV where both side are affected such as post-traumatic ,most severely affected side
should be treated first.
If not response, hand –held vibrator may be used to mastoid during this manoeuvre.
The remission rate may be improved if the is instructed to sleep only on the unaffected side.
Outcomes & complications
In most cases ,attack of BPPV occur in bouts lasting several weeks.Bouts are self-limiting with
remission unpredictable.
In about half ,there is at least one recurrence after a period remission .Remission lasting weeks
,months, or even years.
The patient with repeated bouts of vertigo over several decades ,no abnormalities most likely has
BPPV.
Key points:1)BPPV results in recurrent transient attacks of severe vertigo ,provoked by changes in
head position.
2)BPPV occurs due to the presence of stray otoconia in a semicircular canal duct.
3)A dix-Hallpike manoeuvre produces transient vertigo &nystagmus. And diagnostic.
4) The manoeuvre relocates the stray otoconia & stops attack in most patients.

3. The treatment of positional vertigo:
Diagnostic considerations(p-3809)
Diagnosis of BPPV is made on the basis of typical signs (nystagmus) &symptoms(vertigo &nausea)
provoked by specific positional tests that include the Dix-Hallpike &side-lying tests for posterior
&anterior SSC & the Roll test for the horizontal canal.
It is important to identify correctly the canal &affected side but also to discriminate BPPV from
central pathology.(nystamas direction.duration, latence &fatiqability.)
Specific treatment of BPPV:
In most cases the BPPV symptoms abate within a few weeks,however,in up to 30% of untreated
cases the symptoms may persist for months resulting disability &frustration for the patient.
Specific treatment of p-BPPV
1)Semont’s liberatory manoeuvre:a)From sitting position with the face turned 450 to the unaffected
side.b)the patient is brought rapidly/quickly to the affected side,with face turned upwards by 450.
c)The patient is then swung rapidly to the opposite side ,face turned downwards by 450.
d)The patient is then brought slowly up to the sitting position.
2)Epley’s repositioning manoeuvre:a) The patient is sat on the table with the head turned by 450 to
the affected side.b)bring down rapidly with the head turned by 450 to the affected side &extended
over the edge of the table.c) The head is then turned 900 to the opposite side.d) This is followed by
rotating the head & body 900 facing downwards (1350 fom the supine position) e)The patient is next
brought to the sitting position with the head turned forward.(maintenance at each position&gradual
position changing with 30-seconds interval.)
Factors that may influence outcome of the repositioning manoeuvre:
Mastoid vibrator can be useful in cases when repeated CRP has been unsuccessful.
Post treatment instructions to the patients such as sleeping with two pillow,wearing a coller,avoid
shaking the head,or bending/extending the head for 48hrs after repositioning manoeuvre.
Complications & adverse reactions
Several patients report gait instability following CRP(canalolith repositioning procedure) due to new
position of the canalith in utricle.
Conversion of the posterior canal BPPV into anterior or horizontal canal BPPV.
Nystagmus may convert to a rapid form that persist & unaffected by positional testing due to
canalith jam. This may be treated by mastod vibrator &repositioning procedure.

4. Specific treatment of h-BPPV
Forced prolonged position on the healthy side:Patients with h-BPPV to lie down on the healthy side
for 12hrs to allow the otolithic debris to gravitate to the vestibule by maintaining the affected h-SSC
uppermost.Recovery rate74.3%.
3600 yaw rotation manoeuvre ; The patient head & body is rotated by 3600 in rapid 900 steps &
towards the unaffected ear.a) lying position on the affected side b) to the supine position c) to the
lying position on the unaffected side d) to the supine position e) to the lying position on the affected
side.
Complications h-BPPV: Horizontal semicircular canalolithiasis mey convert to cupulolithiasis after a
rotation manoeuvre.
Conclusion:
In the light of the existing ,patients with BPPV should be treated by any of the appropriate single –
step manoeuvre with which the physician is more confident. Some cases with BPPV may require
additional intervention to the repositioning manoeuvres or exercises.