2. INTRODUCTION
• BPPV is a common cause of dizziness
– BPPV is the most common cause of dizziness in the
elderly
– Approximately 50% of people over the age of 65 will
experience BPPV
– Frequently seen in elderly
– More frequent in females than males
• Characterized by short episodes of dizziness
associated with changes in head position
3. DEFINITION
• Benign--not malignant or life threatening
• Paroxysmal--response (nystagmus) builds,
peaks, fatigues
• Positioning--response provoked by change in
head or body position
• Vertigo--sensation of movement, usually
described as spinning or turning
5. Pathophysiology of BPPV
• Transient episodes of vertigo (<1 minute)
• Initiated by position change
• Characterized by periods of exacerbation and
remission
• Usually unilateral
• Little benefit from medication
6. BPPV Characteristics
• Lying down or getting up
– getting in and out of bed
• Rolling over in bed
• Bending over
– picking something up
• Looking up
– Shaving
– Washing hair in shower
• Going to dentist or beauty salon
7. Mechanism underlying of BPPV
Dislodged otoconia from the utricle settle in a
semicircular canal causing overexcitability
with angular head movements
How do the otoconia become dislodged?
8. Etiology
• Primary or idiopathic BPPV
• Head trauma
• Vestibular neuritis
• Viral labyrinthitis
• History of inner ear pathology
• History of otologic surgery
• Migraines
10. Mechanism Underlying of BPPV
Cupulolithiasis- -otoconia in the utricle break
loose and adhere to the cupula of the
posterior semicircular canal
Canalithiasis--otoconia are free floating in the
posterior semicircular canal; when the head
moves into a provoking position, the otoconia
sink into the most dependent position in the
canal, causing endolymph to move
11.
12. SYMPTOMS
• In the elderly population, BPPV and dizziness
are associated with falls, and falls represent a
significant risk of serious injury and death.
(Oghalai et al., 2000)
13. • Most prominent clinical feature of BPPV is
positional vertigo.
• In addition to vertigo, symptoms include
dizziness, difficulty concentrating, nausea,
imbalance.
• Many patients report prolonged mild
imbalance that some persisted for a few
weeks after resolution of positional vertigo.
(Serafini et al. 1996; Di Girolamo et al. 1998)
14. • Besides that, nystagmus, or also known as
abnormal eye movement, is considered the
hallmark sign of BPPV.
• Since certain head positions exacerbate
symptoms, patients may self limit their
activities, thus affecting social, psychological,
and physical aspects of daily living.
(Sakaida et al., 2003)
15. • BPPV may be experienced for a very short
duration or it may last a lifetime.
• Each single BPPV attack lasts a few seconds.
• But after a series of attacks, patients may
complain of prolonged dizzyness and imbalance
lasting from hours to days.
• The symptoms occurs in an intermittent pattern
that varies by duration, frequency, and intensity.
(Furman & Cass, 1999)
16. Hallpike Test
• Diagnosis of BPPV is commonly made on the
basis of typical signs such as nystagmus and
symptoms including vertigo and nausea
provoked by the Hallpike test.
(Parnes et al. 2003; Hilton & Pinder 2004)
17. The patient is placed in a sitting position with the
head turned 45° towards the affected side and
then reclined past the supine position
18. Management
• Has few ways of treatment:
1.Canalith repositioning procedure / Epley
maneuver
2.Semont maneuver
3.Brandt-Daroffs exercise
4.Drugs medication
5.Surgery
6.Others - DizzyFIX
19. 1. Canalith Repositioning Procedure / Epley maneuver
• was induced by Epley in 1992.
• based on the theory of canalolithiasis (J.M. Epley 1992)
• Function:
- enabled the otolithic debris to move under the
influence of gravity from the posterior semicircular
canal into the utricle (J.M. Epley 1992; Mayo Clinic
2012)
• Evidence based (Stavros G. Korres et al. 2007) :
- Immediately success in 165 patients from 204 patients.
- 23 more patients proved successful after its repetition in
a second session.
- Total success rate was 92.1%
20. • Procedures:
Figure 1: The Epley CRP when the posterior
semicircular canal of the left ear is affected.
21. • TAKE NOTE:
- After carry out this procedure, patient is advised not
to bend over, lie back, or tilt the head during the next
48 hours.
- Patient is asked to sleep in a slightly elevated position.
- Avoid turning during sleep toward the affected ear
side.
- These can be done assisted by someone professionals
who has experiences to do so.
22. Particle Repositioning Maneuver (PRM)
• The modified version of CRP.
• Aim still the same just the procedure has little changes.
(L. S. Parnes et al. 1993; 1997)
“enabled the otolithic debris to move under the influence of
gravity from the posterior semicircular canal into the utricle”
(J.M. Eplet 1992; Mayo Clinic 2012)
• Take less than 5 minutes to complete.
• TAKE NOTE:
- Patients are then typically asked to remain upright for the
next 24–48 hours in order to allow the otoliths to settle
.:. to prevent a recurrence of the BPPV.
23. • Procedures:
Figure 2: Positional repositioning
maneuver with right ear affected
24. 2. Semont maneuver
According to A. Semont et al. 1988,
• A maneuver which only be apply if patient showed
failure towards CRP/PRM treatment.
• Based on the capulolithiasis theory.
• It is the rapid changes if head position freed deposits
that were attached to the cupula.
• Aim/Objectives : still SAME
• Evidence based:
- 711 patients as the subjects.
- 84% response rate after 1 treatment.
- 93% response rate after second treatment.
25. • Procedures:
Figure 3: Semont Maneuver for
right ear affected.
26. • S. J. Herdman et al (1993); Cohen and Jerabek
(1999)
- No difference in efficacy shown between the
Semont (liberatory) manoeuvre and PRM.
• Parnes et al. (2003)
- state the opinion that “the liberatory manoeuvre is
effective but complicated in elderly and obese
patients.
- shows no increased efficacy compared with the
simple particle repositioning manoeuvre (PRM).
27. 3. Brandt-Daroffs exercise
According to Brand Th, Daroff RB (1980) in Physical
therapy for benign paroxysmal positional vertigo.
• based on the theory of cupulolithiasis.
• proposed the first effective therapy for BPPV that
consisted of a set of physiotherapeutic exercises.
• Need to be repeat many times a day for two to three
weeks.
• Presribed by the clinician as home treatment and a
habituation exercise.
• Designed to allow the patient to become accustomed to
the position which causes the vertigo symptoms.
28. • The Brandt-Daroff exercises are performed in a similar
procedures to the Semont maneuver.
• Procedures difference between Brandt-Daroffs exercise and
Semont maneuver is when the patient rolls onto the
unaffected side, the head is rotated toward the affected side
(D. L. Vesely et al. 1996).
According to Theraputic Guidelines (2011),
• Symptoms of giddiness will be shown. But, the symptoms
should resolve over a period of several days in most cases.
• Initial stage of therapy:
- Certain medications may be taken to control any nausea.
- Prolonged use should be avoided.
30. 4. Drugs medication
• Mayo Clinic (2012):
- Drug medication will be given if the patient is
considered to have acute or severe exacerbation
of BPPV.
- But, mostly not indicated.
- Drugs that may be involve are:
anti-histamine (meclizine)
anti-cholinergic (scopolamine).
• This medication is used to treat vertigo/dizziness
syndromes.
31. 5. Surgery
• Only be suggest if the vestibular rehabilition does not work
anymore to the patient.
• Choices of surgical treatment that can be done are:
a) Singular neurectomy (Gacek 1978, 1982, 1995; D. A. Schessel
et al. 1998)
- It is a section of the posterior ampullary nerve
- Sends impulses exclusively from the posterior semicircular
canal to the balance part of the brain.
- Was popularized by Gacek in the 1970s.
- At first the initial reports show high efficacy but there was a
significant risk of sensorineural hearing
- Procedure has been found to be technically demanding.
- Largely been replaced by the simpler posterior semicircular
canal occlusion.
32. b) Posterior semicircular canal occlusion.
- Obstruction of the semicircular canal lumen will prevent
endolymph flow.
- Thus, it effectively:
fixes the cupula
renders it unresponsive to normal angular acceleration forces
to stimulate free-floating particles within the endolymph or a
fixed cupular deposit*
(L. S. Parnes and J. A. McClure 1990, 1991, 1996)
33. 6. Others – DizzyFIX
• Home medical device.
• Has the ability to perform the treatment of Epley maneuver.
• Improves accuracy by comparison to instructions and expert
training alone.
• Evidence based:
- 40 patients suffering from BPPV was given a DizzyFIX.
- After one week of home treatment, 35 patients (88 percent)
had no evidence of nystagmus with Dix-Hallpike maneuvers.
(Bromwich et al. 2008, 2010)
34.
35. • Few tips if a person experience dizziness associated with
BPPV:
Be aware of the possibility of losing your balance,
which can lead to falling and serious injury.
Sit down immediately when you feel dizzy.
Use good lighting if you get up at night.
Walk with a cane for stability if the patient is at risk
of falling.
(Mayo Clinic 2012)
36. References
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1998. Postural control in benign paroxysmal positional vertigo before and after
recovery. Acta Otolaryngol 118:289–93.
• Furman, J.M. & Cass, S.P. 1999 Benign paroxysmal positional vertigo. N Engl J Med
341(21): 1590-6.
• Hilton, M. & Pinder, D. 2004. The Epley (canalith repositioning) manoeuvre for
benign paroxysmal positional vertigo. Cochrane Database Syst Rev (2):CD003162
• Parnes, L.S., Agrawal, S.K. & Atlas, J. 2003. Diagnosis and management of benign
paroxysmal positional vertigo (BPPV). Canadian Medical Association Journal
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• Oghalai, J.S., Manolidis, S., Barth, J.L., Stewart, M.G. & Jenkins, H.A. 2000.
Unrecognized benign paroxysmal positional vertigo in elderly patients. Otolaryngol
Head Neck Surgery Journal 122:630-4.
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• Serafini, G., Palmieri, A.M.R. & Simincelli, C. 1996. Benign paroxysmal positional
vertigo of posterior semicircular canal: results in 160 cases treated with Semont’s
maneuver. Ann Otol Rhinol Laryngol 105:770–5.
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