This document discusses benign paroxysmal positional vertigo (BPPV), including its causes, types, diagnostic tests, and treatment maneuvers. It provides details on: - Posterior canal BPPV is the most common type, accounting for 81-89% of cases. The Dix-Hallpike test is used for diagnosis. Treatment includes particle repositioning maneuvers like Epley's maneuver. - Horizontal canal BPPV, which accounts for 8-17% of cases, is diagnosed using tests like the supine roll test. Treatments include maneuvers like the Lempert maneuver. - Anterior canal BPPV is rare but can result from treatments for other forms

1. BPPV AND PARTICLE REPOSITIONING
MANEUVERS
DR.ANITA BHANDARI
CONSULTANT NEUROTOLOGIST
VERTIGO AND EAR CLINIC
JAIPUR

2. The ampulla contains the cupula – a gelatinous mass with the same
density as the endolymph. Cupula forms an impermeable barrier across
the lumen of the ampulla. Hence the particles in scc may only exit via
the end with no ampulla.

3. SECONDARY CAUSES OF BPPVSECONDARY CAUSES OF BPPV
Head injury
Prolonged bed rest
Vestibular neuritis
Meniere’s disease – hydropically induced damage to
macula of utricle
Migraine
Ear surgery

5. BPPV by canal typeBPPV by canal type
Posterior Horizontal Anterior
Estimated
frequency
81-89% 8-17% 1-3%
Provocative
maneuver
Dix Hallpike Supine Roll Test
(Pagnini-McClure)
Dix Hallpike
Nystagmus Upbeat,
torsional
Horizontal
Direction Changing
Downbeat,
torsional

6. POSTERIOR CANAL BPPVPOSTERIOR CANAL BPPV
Most common– posterior canal is most gravity
dependant in upright and supine position
Once debris enter the post. canal ,the cupula at the
shorter most dependant arm trap the debris.
Debris can exit only through the longer arm through the
crus commune [non-ampullary]

10. CAUSE OF LIMITEDCAUSE OF LIMITED
DURATIONDURATION

11. CAUSE OF FATIGUABILITYCAUSE OF FATIGUABILITY

12. DIX-HALLPIKE TESTDIX-HALLPIKE TEST

13. EPLEYEPLEY’S MANEUVER’S MANEUVER

14. EPLEYEPLEY’S MANEUVER’S MANEUVER

15. EPLEYEPLEY’S MANEUVER’S MANEUVER

16. SEMONTSEMONT’S MANEUVER’S MANEUVER

17. SEMONTSEMONT’S MANEUVRE’S MANEUVRE

18. SEMONTSEMONT’S MANEUVER’S MANEUVER

19. SEMONTSEMONT’S MANEUVER’S MANEUVER
Liberatory maneuver for pBPPV and cupulolithiasis
Used to overcome otoconia jam after Epley’s
maneuver

20. BRANDT – DAROFF EXERCISESBRANDT – DAROFF EXERCISES
Used as a home program
Indications
o Posterior canal cupulolithiasis
o Persistant posterior canal canalithiasis
Mechanism
o Dislodge debris attached to cupula
o Habituation through central compensation

21. BRANDT – DAROFF EXERCISESBRANDT – DAROFF EXERCISES

22. BRANDT – DAROFF EXERCISESBRANDT – DAROFF EXERCISES
Things to remember
o The exercises may dislodge more otoconia from the
utricle causing an increase in symptoms.
o May cause multiple canal involvement.
o Important to hold for 30 seconds in each position.

23. HORIZONTAL SCC BPPVHORIZONTAL SCC BPPV
Pagnini-McClure maneuvre
Geotropic nystagmus – debris are away from
ampulla , side showing stronger nystagmus is the
side involved
Apogeotropic nystagmus – indicates cupulolithiasis

24. LOWER INCIDENCE OFLOWER INCIDENCE OF
HORIZONTAL CANAL BPPVHORIZONTAL CANAL BPPV

26. SEQUENCE OF EVENTS INSEQUENCE OF EVENTS IN
hBPPVhBPPV

28. McCLURE PAGNINI MANEUVERMcCLURE PAGNINI MANEUVER
SUPINE ROLL TESTSUPINE ROLL TEST

29. SUPINE ROLL TESTSUPINE ROLL TEST

30. LEMPERT MANEUVRELEMPERT MANEUVRE

31. LEMPERTLEMPERT’S BARBECUE ROLL’S BARBECUE ROLL

32. GUFONI MANEUVERGUFONI MANEUVER

33. VANUCCHI MANEUVERVANUCCHI MANEUVER
Forced prolonged positioning
Sleep in lateral position with healthy ear down for 12
hours.

34. CUPULOLITHIASISCUPULOLITHIASIS
Coined by Schuknetch
Rare , more common in horizontal canal
Caused by otoliths attached to cupula of scc
When cupula is horizontal no vertigo
When non-horizontal constant input persistant
dizziness
Nystagmus : persistant non-fatiguable as long as patient is
in the same position

36. SEQUENCE OF EVENTS INSEQUENCE OF EVENTS IN
CUPULOLITHASISCUPULOLITHASIS

38. ANTERIOR CANAL BPPVANTERIOR CANAL BPPV
Anterior canal BPPV is usually transitory and
most often the result of “canal switch” that
occurs in the course of treatment more
common forms of BPPV

39. SUBJECTIVE BPPVSUBJECTIVE BPPV
No nystagmus is detected but patient feels dizzy on
provocative tests
PRP beneficial
Reasons
o Subtle nystagmus
o Fatigued nystagmus
o Inadequate neural signal to stimulate the VOR

40. CONTRAINDICATIONS OFCONTRAINDICATIONS OF
PARTICLE REPOSITIONINGPARTICLE REPOSITIONING
Cervical spine problems
Uncontrolled hypertension
Retinal detachment

41. OTHER CAUSES OFOTHER CAUSES OF
POSITIONAL NYSTAGMUSPOSITIONAL NYSTAGMUS
Direction changing nystagmus – central
Down beating positional nystagmus – nodulus
Down beating nystagmus on Dix-Hallpike – anterior
canal BPPV . Treated by Epley’s maneuvre

42. SURGERYSURGERY
Very limited role
o Posterior canal occlusion
o Singular neurectomy

43. THANKSTHANKS