Benign Paroxysmal Positional Vertigo (BPPV) Faints, fits and funny turns for the physician Monday 18 January 2016

Bristol Marriott Royal Hotel

Dr Peter West, Consultant in Audiovestibular Medicine, Queen Alexandra Hospital, Portsmouth

CASE 1: 55 year old lady • 4 week history sudden onset of imbalance – feels constantly “drunk” • Short bursts of vertigo especially when reaching up (hanging washing), bending down or getting up quickly • Feels too dizzy to drive

• Intermittent tinnitus • Chronic neck/back pain and stiffness: sleeps on 3 pillows Examination: Anxious.

Tachycardia 100

BP 160/100

Wearing cervical collar, recommended by chiropractor. No response to The Four S’s: Serc, Stemetil, Stugeron, Syringing

GP’s conclusion

“I can only imagine it has got to be a mechanical neck problem because of the fact that it is only there in these positions.”

GP referral to radiology for “CT of balance mechanism or MRI of neck” MRI of internal auditory meatuses: No abnormality

MRI of cervical spine: Mild cervical spondylosis but no significant disc protrusion

Conclusion: “Not having found an adequate cause to explain her symptoms, it may be worth a return appointment for MR angiography of her carotid and vertebral arteries.”

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DIX-HALLPIKE TEST ..

BPPV – findings on Hallpike test • • • • • •

Latent period: 2-40 secs Nystagmus: Upbeat and torsional to undermost ear Vertigo: usually severe, for duration of nystagmus Adaptation: resolves within 30 secs Reversal of nystagmus: on sitting up Fatiguability: goes away on repeating test

• Responds to CANALITH - REPOSITIONING (EPLEY) MANOEUVRE

Anatomy of the labyrinth Anterior semicircular canal

Posterior semicircular canal

Horizontal semicircular canal Otolith organs

Treatment of BPPV - Epley manoeuvre

(R) Epley manoeuvre – Start: Head turned 45º (R)

(R) Epley manoeuvre – 1. (R) Hallpike test: Head 45º (R), 30º down

(R) Epley manoeuvre – 2. (L) Hallpike position Head 45º (L), 30º down

(R) Epley manoeuvre – 3. On (L) side, 45º face down

(R) Epley manoeuvre – 4. Sit up, keeping head turned (L)

(R) Epley manoeuvre – 5. Head forward 30º

SEMONT LIBERATORY

MANOEUVRE for (R) posterior SCC

(R) Semont manoeuvre – 1. (R) Side-lying test

(R) Semont manoeuvre – 2. Throw rapidly onto (L) keeping head turned to (L)

(R) Semont manoeuvre – 3. Lying on (L) keeping head turned to (L)

BPPV characteristic symptoms - 1 Classical provoking movements: • Lying flat

• Sitting up from lying flat • Turning over in bed • Looking up (extending neck) • Bending down (flexing neck), especially to side

BPPV characteristic symptoms - 2 Vertigo: Usually rotational

May be “falling through bottom of bed” On getting up, “being thrown back onto bed”

Duration: Usually 5 - 20 seconds. Always under 1 minute May notice latent period of up to half a minute

BPPV characteristic symptoms - 3 Accompanying symptoms: NO neurological or audiological symptoms BUT BPPV may complicate other inner ear disease Pattern of attacks: Bouts: days, weeks or months at a time, with symptom free periods OR, may occur every day for years on end Constant unsteadiness rather than vertigo may be the main symptom

Not all positional vertigo is due to canalithiasis of the posterior SCC…. (1) • Cupulolithiasis • Horizontal canal BPPV

Horizontal SCC BPPV • No more than 5% of BPPV. • Vertigo turning in bed (less on looking up). • Roll test: Lie supine, one pillow Turn head sharply through 90º Transient vertigo with geotropic nystagmus Affected ear is side with worse symptoms/nystagmus

1

2 3

• Cupulolithiasis gives sustained, apogeotropic nystagmus. • Treat canalolithiasis with BBQ manoeuvre.

BBQ Roll manoeuvre for (R) Horizontal Canal BPPV 1. Lie supine. Roll head 90º (R)

Best to use one pillow

4. Raised on elbows, keep head horizontal

6,7. Keep head turned (R)

Not all positional vertigo is due to canalithiasis of the posterior SCC…. (2) • Cupulolithiasis • Horizontal canal BPPV • Anterior canal BPPV

Anterior SCC BPPV • Rare! • Hallpike or • Rose (Head-hanging) test: Nystagmus is downbeat

with torsion to the affected ear

• Treat with: Epley manoeuvre (affected side) Reverse Semont manoeuvre (start nose down) Deep Head Hanging Manoeuvre

Physical therapy management of Anterior Canal Benign Paroxysmal Positional Vertigo by the Deep Head Hanging Maneuver Amer A. Al Saif, Samira Alsenany Journal of Health Sciences 2012; 2(4): 29-32

Not all positional vertigo is due to canalithiasis of the posterior SCC…. (3) • • • •

Cupulolithiasis Horizontal canal BPPV Anterior canal BPPV Central (cerebellar) disorders may be asymptomatic – do a Hallpike in ALL cases of imbalance

Central (cerebellar) disorder?

• In (mainly) severe posterior SCC BPPV, there may be (mild) sustained downbeat nystagmus on the contra-lateral side.

• Debris in uppermost posterior SCC falls back onto the cupula. • Resolves after successful Epley.

CASE 2: 59 year old man Admitted under cardiologists with dizziness.

Referred with diagnosis of BPPV: • Vertigo on lying down - 4 pillows - sleeps sitting up. • Latent period. • Vertigo “lasts 5 minutes” - stops when he sits up.

• Vertigo provoked by getting up and by bending. • Balance generally “not too bad”.

Additional history:

• Lying flat induces breathlessness as well as vertigo. • Symptoms helped by oxygen. • Mild micturition syncope.

Hallpike test: At 15 seconds, acute dyspnoea and vertigo. No nystagmus. At 40 seconds, had to sit up, inducing severe pallor and dizziness but no nystagmus.

Outcome: Assessed (and turned down) for heart transplant.

Not all positional vertigo is due to canalithiasis of the posterior SCC…. (4) • • • •

Cupulolithiasis Horizontal canal BPPV Anterior canal BPPV Central (cerebellar) disorders may be asymptomatic – do a Hallpike in ALL cases of imbalance

• Orthopnoea (!)

Ultimately, diagnosis is by RESPONSE TO TREATMENT

…the patient who fails to respond to Canalith Repositioning Manoeuvres

(MAXIMUM of 3) MUST be referred for a specialist opinion

Portsmouth audit of BPPV 2011-13 • 598 new patients (no BPPV in previous year). • Seen by 2 consultants (PW and Dr Victor Osei-Lah) over 2 years, 2011-12. • Full data on 568.

Age range

…in other words, BPPV accounts for AT LEAST 25% of all dizziness (presenting to a Balance Clinic) in the OVER-50s.

Duration of vertigo Duration

Number

%

Less than 3 months

199

35 %

3 – 12 months

238

42 %

1 – 3 years

52

9%

More than 3 years

56

10 %

Unknown

23

4%

Location of BPPV Type

Number

%

Posterior SCC - (R)

322

56.7

- (L)

187

33

- Bilateral

34

6

2

0.4

- (L)

12

2

- Bilateral

0

0

- (R)

5

0.8

- (L)

1

0.2

- Bilateral

0

0

5

0.9

Horizontal SCC - (R)

Anterior SCC

Mixed

95.7%

2.4%

1%

Aetiology No. Migraine headache only 27 Migraine vertigo only 16 Migraine both 17 TOTAL migraine

% 7 4.2 4.5 15.7

Outcome after 1st treatment (568 cases) Success: 45% Partial success: 10% Failure: 6% Unknown: 39%

Results in 261 cases with known outcome 1st treatment success: 73% partial success: 17% failed: 10% After 2nd treatment: 90% success

Recurrence rate 261 cases Recurrence

Cumulative %

1 month

1

3 months

8.4

6 months

16

12 months

22

18 months

23

2 years

26

Recurrent BPPV • Recurrence is NOT a treatment failure, just bad luck. • More likely if post-traumatic (may also be more resistant to treatment). • Patients can be taught self-treatment.

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