Benign Paroxysmal Positional Vertigo (BPPV) A Little Rock and Roll Talk

Thomas G. Brammeier, M.D., F.A.C.S. Director of the Hearing & Balance Center

Epidemiology of BPPV 

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Most common type of vertigo, approximately 25% occurrence at the Scott & White, Hearing and Balance Center. Increases with age. BPPV occurs in approximately 1-3% in teens to 30% in the elderly. Age of onset occurs between 5th and 7th decade of life. However, there is an increase in occurrence in elderly women (greater than 60 years of age), 2:1. 1. Baloh R, et.al. Neurology 37:371, 1987.

2. Mizukoshi K, Acta Otolaryng. 447: 67, 1987

3. Froehling D, et al. Maya Clinic Proc 66:596, 1991

Etiology of BPPV 

Primary BPPV is idiopathic. 

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occurrence rate is 50-70%.

Secondary BPPV can be caused by head trauma, migraines, Meniere’s disease, viral labyrinthitis, vestibular neuronitis, stapedectomy, perilymph fistula, or chronic otitis media.

Historical Background of BPPV 

1921, Barany first described the manifestations of BPPV.

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1952, Dix and Hallpike described the classic maneuver.

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1969, Schuknecht described the otoconia floating from utricle into the posterior semicircular canal.

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1992, Epley described the canalith repositioning maneuver, as the Epley Maneuver.

Otolaryngology Head & Neck Surgery, 3rd edition, 1998.

Macula of the Utricle

Otoconia Particles

Pathophysiology of BPPV 

Canalithiasis: 

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Free-floating otoconia particles come from the maculae of the labyrinth and float into the posterior semicircular canal. The posterior canal is the most gravity-dependent part of the vestibular labyrinth. The mechanism of nystagmus is that the otoconia particles reach a critical mass load in the dependent portion of the posterior canal. When the head turns in the plane of the posterior canal, the inertia of otoconia critical mass load cause a fluid drag that must overcome the endolymph fluid pressure within the posterior canal to cause deflection of the cupula. This is the reason for the latency and the cresendo nystagmus seen during the Dix-Hallpike maneuver.

Pathophysiology of BPPV Canalithiasis: 

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The canalith critical mass load causes the movement of endolyph fluid away from the cupula to induce ampullifugal cupular deflection causing an excitatory response. This causes torsional nystagmus in the plane of the posterior canal. (Ewald’s Law) The nystagmus has limited duration because of endolymph fluid ceases when the canalith mass reaches the limit of descent within the semicircular canal. Upon reversing the direction of endolymph fluid by the change in the position of the head, the nystagmus reverses direction. The response is fatigable as the particles become dispersed along the canal and become less effective in creating endolymph fluid inertia and cupular deflection.

Epley, Ann NY Academ Sci 2001

Cohen, Ann Otolaryng. 1964

Diagnosis of BPPV Medical history: 

Intermittent vertigo associated with changes in head positions, i.e. rolling over in bed, looking up, and bending over.

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Duration is 20-30 seconds.

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No fluctuation of hearing or tinnitus.

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May have nausea, sweating, pallor and vomiting with symptoms of vertigo.

Diagnosis of BPPV Past Medical History: 

Migraines, Meniere’s disease, closed head injury, labyrinthitis, chronic otitis media, otosclerosis, and perilymphatic fistula.

Physical Examination: 

Normal except an abnormal (positive) Dix-Hallpike test.

Dix-Hallpike test is a very specific test, but not sensitive for the diagnosis of BPPV. An abnormal (positive) Dix-Hallpike test may indicate BPPV, but a normal Dix-Hallpike does not rule out BPPV.

Dix-Hallpike Test   

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Patient is sitting up on the table and the table is tilted 30 degrees down. The head is turned 45 degrees to the side being tested. Move the patient into the supine position while holding the head 45 degrees toward the ear being tested. Always have an assistant help you with the patient positioning. Use Frenzel’s goggles or thick reading glasses to observe the eyes. Tests for the posterior semicircular canal on the side the head is turned.

Diagnosis of BPPV Five characteristics of BPPV 1. 2. 3. 4. 5.

Latency Short duration Reversibility Fatigability Direction

Diagnosis of BPPV 1. Latency 

After the positioning the patient will have a pause of 2-10 seconds before the start of the nystagmus and symptoms of vertigo.

2. Duration 

The nystagmus and vertigo will last no longer than 20-60 seconds.

Diagnosis of BPPV 3. Reversibility 

The direction of the nystagmus in the supine position will reverse upon positioning the patient in the sitting position.

4. Fatigability 

Repeating the Dix-Hallpike test will result in progressively milder symptoms of vertigo and nystagmus.

Diagnosis of BPPV 5. Direction 

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Depends directly on which labyrinthine semicircular canal is affected by the otoconia. 90-95% of the time, otoconia affects the posterior semicircular canal. 5-7% of the time, otoconia affects the horizontal semicircular canal. Rarely affects the superior semicircular canal.

Parnes, Neurotology 2ed.

Diagnosis of BPPV Direction of nystagmus 

Posterior semicircular canal 

Right ear down: 

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Right ear up: 

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Nystagmus is up-beating (ageotrophic) with torsional counterclockwise movements.

Left ear down: 

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Nystagmus is down-beating (geotrophic) with torsional clockwise movements.

Nystagmus is down-beating (geotrophic) with torsional counterclockwise movements.

Left ear up: 

Nystagmus is up-beating (ageotrophic) with torsional clockwise movement.

Treatment of BPPV Canalith Repositioning Maneuver: Brammeier’s technique: During the entire canalith repositioning maneuver, the head is held in position at 15-30 second intervals and the vibrator (oscillator) is applied to the skull. 1.

The patient’s head is turned 45 degrees and the patient is lowered so that the affected ear is tilted down at approximately 30 degrees from the horizontal plane. Hold this position for 15-30 seconds. Apply the oscillator to the skull bone.

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The patient’s is kept supine and the head is turned 45 degrees to the midline position. Hold this position for 15-30 seconds and continue with the oscillator.

Treatment of BPPV Canalith Repositioning Maneuver: Brammeier’s technique: 3.

The patient is kept supine and the head is turned 45 degrees away. Hold this position for 15-30 seconds and continue with the oscillator on the skull.

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Roll the patient on their side while holding the head in position. Turn the head 45 degrees to the floor with the patient’s chin touching the shoulder. Hold this position for 30 seconds and continue with the oscillator.

Treatment of BPPV Canalith Repositioning Maneuver: Brammeier’s technique: 5.

Sit the patient up leaning over greater than 90 degrees with the horizontal plane, the head in the midline position tilted slightly forward. Have the patient lean over to the opposite side for 5 seconds then in the center positioned. Hold this position for 15-30 seconds and continue the oscillator. After 5-10 seconds, position the patient 90 degrees and continue with the oscillator for the remaining 10-20 seconds.

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Bring the head to the neutral position. May apply the soft neck collar to wear for 24 hours.

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Follow up with a Dix-Hallpike test to confirm resolution of BPPV.

Problems and Complications with Canalith Repositioning Maneuver 

Canalith jam 

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Caused by moving too fast through the canalith repositioning maneuver. The otoconia particles clog the semicircular canal and cause severe vertigo. Treatment: reverse the last two steps of the canalith repositioning maneuver. The oscillator helps shakes the otoconia particles loose within the semicircular canal.

Problems and Complications with Canalith Repositioning Maneuver 

Severe nausea and vomiting     

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Occurs approximately in 1-2% of patients. Stop the procedure. Make sure it is not a canalith jam. Position the patient to allow for vomiting. Treatment: May need to pre-medicate patient before attempting another canalith repositioning maneuver. Try the canalith repositioning maneuver on a different day.

Neck pain 

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Contraindications for Dix-Hallpike testing and Canalith Repositioning Maneuver include: history of recent neck trauma, severe cervical rheumatoid arthritis, any cervical instability, cervical myelopathy or radiculopathy. Always control the head and body movements with an assistant.

Problems and Complications with Canalith Repositioning Maneuver 

Converting posterior BPPV to horizontal BPPV. 

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Moving too fast through the canalith repositioning maneuver and not keeping the head tilted forward in the last two steps of the procedure. Occurs approximately 1-5%.

Failure for BPPV to resolve. 

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It is possible to have a recurrence within 1-2 weeks after treatment. Treating the wrong semicircular canal. BPPV is not the true underlying problem.

White, J. Cleveland Clinic Journal of Medicine Sept 2004

Treatment for BPPV Outcomes of Canalith Repositioning Maneuver Numerous published variations on the techniques of Canalith Repositioning Maneuver.  Greater than 80% effective on first repositioning maneuver.  Higher success after multiple repositioning maneuvers, oscillation, tilting the head in last two steps, and timing of positional changes.  Dr. Brammeier’s technique has overall an approximately 95% success rate.  Recurrence rate of approximately 20%.

White, J. Otology & Neurotology, 2005