1. Benign Paroxysmal Positional
Vertigo

2.  Most common - labyrinthine dysfunction
 abnormal sensation of motion that is elicited by c e rta in
c ritic a l p ro vo c a tive p o s itio ns
 Provocative positions
 Head turn to affected side - getting out of bed
 Extend head back to look up “Top shelf vertigo”
 Causes
 Idiopathic – 50%
 Head trauma, middle ear infection, viral labyrinthitis,
ear surgery

3. Pathophysiology
 Otoliths (calcium
carbonate
particles) -normally
attached to a
membrane in
utricle & saccule
 Utricle is connected
to semicircular
canal
 Two theories
 Canalolithiasis
 Cupulolithiasis

4. Canalolithiasis
 Otoliths displaced from utricle
- enter the posterior
semicircular duct (most
dependent SCC )
 Changing head position
relative to gravity causes the
free otoliths to gravitate
through the canal.
 The concurrent flow of
endolymph stimulates the hair
cells of the affected
semicircular canal causing
vertigo.

5. Cupulolithiasis
 Otoconia attached to
cupula of scc
 Change in head
position result in
displacement of
cupula results in
vertigo.

6.  Sixth decade
 F>M
 Clinical features
 Sudden onset rotatory vertigo
 Few secs
 Triggered by provocative movements
 No other aural symptoms

7. Dix-Hallpike maneuvre
 Pt seats on the table
 Pt’s head held, turned 45
deg to Rt & pt placed at
supine position – head
hangs 30 deg below
horizontal
 Pt’s eyes observed for
nystagmus
 Test repeated on Lt side

8. Comparision of positional nystagmus of BPPV
with lesions of the CNS
BPPV CNS
Latent period A few seconds nil
Distress Present nil
Direction of
Direction fixed – towards
nystagmus
the undermost ear
Direction changing
Duration of
nystagmus
Less than 30 sec Persists while
position
maintained
Fatiguablity Nystagmus stop with
repeated testing
Nystagmus
persists with
repeated testing

9. Epley’s manoeuvre for left posterior
semicircular canal BPPV

10.  (S) Start: patient is seated
 (1) Place head over end of table, 45 degrees to left.
 (2) Keeping head tilted downward, rotate to 45 degrees
right.
 (3) Rotate head and body until facing downward 135
degrees from supine.
 (4) Keeping head turned right, bring patient to sitting
position.
 (5) Turn head forward, chin down 20 degrees.
 Pause at each position until nystagmus approaches
termination

11. Instructions following Epley’s maneuvre
 Rest 10 min
 Sleep in semi-recumbent
 For at least 1 week
 Use two pillows
 Avoid bad side
 No head turning far
up or down

12. Surgical mangement
 Posterior canal wall
plugging
 debris can no longer
move within the canal
 Singular nerve
section
 Section the nerve that
transmits information
from the posterior
semicircular canal
ampulla toward the
brain.

13. Differential diagnosis of
Vertigo

14. “Subjective sense of imbalance”
 History
 Rotatory ?
 Onset (1st episode)
 Duration
 Progression
 Severity
 Episodic ?
 Aggravating or relieving
factors
 Associated
auditory/neurological
symptoms
 h/o chronic ear ds, trauma,
surgery, intake of drugs

15.  Rotatory
 Episodic
 Seconds
 Hours
 Prolonged
Weeks
 Unsteadiness
 Episodic
 Seconds
 Hours to days
 Prolonged
Weeks to months

16. Rotatory vertigo
Episodic - Few seconds Episodic - Few min to 24 hours
 BPPV
 Labyrinthine fistula
 Perilymphatic fistula
 Caloric effect
 Cervical vertigo
 Meniere’s disease
 Delayed
endolymphatic
hydrops
 Following middle
ear surgery

17. Prolonged - Days to weeks
 Vestibular neuronitis
 Acute labyrinthitis
 Trauma
 Head injury
 Labyrinthectomy
 Vestibular neurectomy
 Secondaries in CP angle

18. Unsteadiness
Episodic - seconds Episodic – hours to days
 Rapid movements  Drugs
 Tranquilisers,
anticonvulsants
 Travel sickness
 hyperventilation

19. Prolonged – weeks to months
 Late stage of vestibular neuritis, acute
labyrinthitis
 Elderly patients
 Drugs
 Anticonvulsants, Gentamicin
 Vestibular schwannoma
 Functional

20.  Examination
 ENT
 Nystagmus
 Involuntary, rhythmical, oscillatory movement of
eyes
 Slow / fast component – direction of the
nystagmus
 Procedure
 Examiner keeps finger about 30 cm from the
patients eyes in the central position & moves
it right or left
 Do not exceed 30 degree from the centre
 Enhanced with Frenzel glasses or in darkness

21.  Otoscopic examination & Tuning fork test
 Fistula test
 Induce nystagmus - pressure changes in the
external ear which are then transmitted to labyrinth
 pressure induced by
 Intermittent pressure over the tragus
 Siegel’s pneumatic speculum

22.  Fistula test negative – normal
 Fistula test positive
 Labyrinthine fistula
 Perilymph fistula
 Post stapedectomy fistula
 False negative fistula test
 Cholesteatoma covering the fistula
 False positive fistula test ( positive fistula test in
absence of fistula)
 Meniere’s disease ( Hennebert’s sign)

23.  Cranial nerves
 Cerebellar function
 Gait
 Romberg’s test
 Dysmetria
 Dysdiadokokinesia

24. Management
 Investigations
 Audiomety
 Caloric test
 Induce nystagmus by thermal
stimulation of vestibular system
 Bithermal caloric test
 Supine, head tilted forward 30 deg
 Ears irrigated with water
 40 sec
 Alternately with water at 30
& 44 deg C

25.  Time taken from irrigation to end of nystagmus
charted on calorigram
 Cold water – nystagmus to opposite side
Warm water – nystagmus to same side
(COWS)
 Depending upon the response to caloric test
 Canal paresis – depressed function of ipsilateral
labyrinth, vestibular nerve, vestibular nuclei
 Directional preponderance – peripheral and central
lesion

26.  Electronystagmography
 Method of detecting & recording nystagmus
 Rotational chair test
 Computerized dynamic posturography

27.  Treatment
 Suppress vestibular symptoms
 Wait for vestibular compensation
 Treat the underlying cause
 Medical
 Surgical