Benign Paroxysmal Positional Vertigo (BPPV)

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Benign Paroxysmal Positional Vertigo (BPPV)

Otology/Audiology
Author Credentials 

Betty S. Tsai Do, MD
Associate Physician
Head and Neck Surgery
The Permanente Medical Group
Walnut Creek, CA

 

Module Summary

Benign Paroxysmal Positional Vertigo (BPPV) is a common manifestation of vestibular dysfunction. A detailed history and physical examination is key to its diagnosis. Treatment by canal repositioning maneuvers is often successful. However, it is important to assess other risks factors associated with BPPV that may increase patient comorbidities. Rarely surgical intervention is warranted.

Module Learning Objectives 
  1. Distinguish (Benign Paroxysmal Positional Vertigo) BPPV from other causes of vertigo through history and physical examination.
  2. Describe the different mechanisms of the pathogenesis of BPPV.
  3. Be able to perform canal repositioning maneuvers to treat BPPV.
  4. Explain the alternative treatment options for intractable BPPV unresponsive to canal repositioning maneuvers including vestibular rehabilitation and surgical occlusion of the posterior canal.

 

Anatomy

Learning Objectives 
  1. Review the anatomy of the semicircular canals.
References 
  1. Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003;169(7):681-93.

Pathogenesis

Learning Objectives 
  1. Discuss the contribution of otoconia and otolithic membrane fragments in causing BPPV.
  2. Summarize the variants of BPPV.

 

References 
  1. Kao WT, Parnes LS, Chole RA. Otoconia and otolithic membrane fragments within the posterior semicircular canal in benign paroxysmal positional vertigo. Laryngoscope. 2017 Mar;127(3):709-714.
  2. Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med. 1999;341:1590-1596.
  3. Lopez-Escamez, JA, Molina, MI, Gamiz, MJ. Anterior semicircular canal benign paroxysmal positional vertigo and positional downbeating nystagmus. Am J Otolaryngol. 2006;27:173-178.
  4. Buki, B. Benign Paroxysmal Positional Vertigo – Toward New Definitions. Otol Neurotol. 2014 Feb;35(2):323-8.  
  5. Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107(3):399-404.

 

Basic Science

Learning Objectives 
  1. Review the basic function of the vestibular system.
References 
  1. Kingma H and van de Berg, R. Anatomy, physiology, and physics of the peripheral vestibular system. Handb Clin Neurol. 2016;137:1-16.

Incidence

Learning Objectives 
  1. Cite the incidence of BPPV and the associated costs to the healthcare system.
References 
  1. von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry. 2007;78:710-715.

Patient Evaluation

Learning Objectives 
  1. Describe the findings on the Dix-Hallpike maneuver in patients with BPPV.
  2. Explain the evaluation for horizontal semicircular canal BPPV.

 

References 
  1. Baloh RW, Honrubia V, Jacobson K. Benign positional vertigo: clinical and oculographic features in 240 cases. Neurology. 1987;37:371-378.
  2. Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med. 1999;341:1590-1596.
  3. White JA, Coale KD, Catalano PJ, et al. Diagnosis and management of lateral semicircular canal benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2005;133:278-284.
  4. Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017 Mar;156(3_suppl):S1-S47.

 

Measurement of Functional Status

Learning Objectives 
  1. Describe how the Dizziness Handicap Inventory measures the impact of dizziness on everyday life.
References 
  1. Jacobsen GP and Newman CW. The development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg. 1990 Apr;116(4):424-7.

Imaging

Learning Objectives 
  1. Recognize the indications of imaging when a diagnosis of BPPV is suspected.
References 
  1. Sharma A, et al; American College of Radiology. Expert Panel on Neuroimaging: Vertigo and Hearing Loss. Reston, VA: American College of Radiology; 2018. Available: https://acsearch.acr.org/docs/69488/Narrative/
  2. Jacobson GP, Butcher JA, Newman CW, et al. When paroxysmal positioning vertigo isn’t benign. J Am Acad Audiol. 1995;6:346-34.
  3. Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017 Mar;156(3_suppl):S1-S47.

 

Treatment

Learning Objectives 
  1. Explain the utility of various repositioning maneuvers, such as the Epley, Brandt-Daroff, and Semont, in the treatment of BPPV.
References 
  1. Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107(3):399-404.
  2. Oron Y, et al. Treatment of horizontal canal BPPV: pathophysiology, available maneuvers, and recommended treatment. Laryngoscope. 2015 Aug: 125(8): 1959-64.
  3. Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol. 1980;106:484-485.

 

Medical Therapies

Learning Objectives 

Discuss the use of medications in the acute management of BPPV.

References 
  1. Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017 Mar;156(3_suppl):S1-S47.
  2. Jung HJ, Koo J-W, Kim CS, Kim JS, Song JJ. Anxiolytics reduce residual dizziness after successful canalith repositioning maneuvers in benign paroxysmal positional vertigo. Acta Otolaryngol. 2012;132:277-284.
  3. Guneri EA, Kustutan O. The effects of betahistine in addition to epley maneuver in posterior canal benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2012;146:104108.

 

Surgical Therapies

Learning Objectives 
  1. Be familiar with the surgical techniques and outcomes to treat intractable BPPV.
References 
  1. Leveque M et al. Surgical therapy in intractable benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2007 May; 136(5):693-8.
  2. Ramakrishna et al. Efficacy and safety of bilateral posterior canal occlusion in patients with refractory benign paroxysmal positional vertigo: case report series. Otol Neurotol. 2012 Jun; 33(4):640-2.

 

Rehabilitation

Learning Objectives 
  1. Be familiar with the different exercises used in vestibular rehabilitation.
References 
  1. Herdman, S.J. Vestibular rehabilitation. Curr Opin Neurol. 2013 Feb;26(1):96-101.

Case Studies

  1. 68 year old presents with frequent falls with episodic vertigo. Spells are typically under a minute primarily with laying down or getting up quickly. He has difficulty sleeping at night as rolling over in bed triggers the spells. What further work up is needed? What are his treatment options?
  2. 45 year old presents a 2 year history of intermittent vertigo which started after a car accident. Initially after the Epley maneuver, he was feeling better. However, a couple of days later, he continues to have brief episodic vertigo but not relieved with the Epley maneuver. What evaluation would you perform at this time? Any further testing needed? How would you counsel the patient? Would you offer surgery?

 

References 
  1. Abbott J, et al. Assessment for benign paroxysmal vertigo in medical patients admitted with falls in a district general hospital. Clin Med (Lond). 2016 Aug;16(4):335-8.
  2. Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017 Mar;156(3_suppl):S1-S47.
  3. Liu H. Presentation and outcome of post-traumatic benign paroxysmal positional vertigo. Acta Otolaryngol. 2012 Aug;132(8):803-6.

 

Complications

Learning Objectives 
  1. Describe associated factors that can be associated with BPPV that can affect patient morbidity, such as falls.
References 
  1. Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017 Mar;156(3_suppl):S1-S47.
  2. Talaat, HS et al. Low bone mineral density and vitamin D deficiency in patients with benign positional paroxysmal vertigo. Eur Arch Otorhinolaryngol. 2015. Sep; 272(9):2249-53.
  3. Yu S, Liu F, Cheng Z, Wang Q. Association between osteoporosis and benign paroxysmal positional vertigo: a systematic review. BMC Neurology. 2014;14:110.

 

Review

Review Questions 
  1. How is BPPV diagnosed?
  2. How is posterior canal BPPV distinguished from horizontal canal BPPV?
  3. What maneuvers can be used for BPPV?
  4. What is the utility of surgical intervention for BPPV?

 

References 
  1. Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017 Mar;156(3_suppl):S1-S47.
Resources 

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