Benign Paroxysmal Positioning Vertigo (BPPV)

1. Benign ParoxysmalPositioning Vertigo(BPPV) Tracy Murphy, Au.D.

2. Role of the Audiologist in the diagnosis and treatment of the dizzy patient

3. Perspective Many disciplines address some functional aspects of balance • Otolaryngology • Audiology • Neurology • Cardiology • Physical / occupational therapy • Ophthalmology • Psychology/Psychiatry

4. No single discipline can claim exclusive control over the domain of dizziness

5. Broad perspective – multidisciplinary approach Understand cause and effect relationships as they pertain to dizziness and balance Be more than a technician – 3 sources of knowledge Patient experience Survey signs and symptoms Knowledge of the discipline

6. Diagnostic Acumen All three knowledge sources are critical in order to come up with the correct diagnosis Test data must be placed into the context of each specific case to determine its significance

7. Audiologists have so much to offer…

8. BPPV

9. 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 • Characterized by short episodes of dizziness associated with changes in head position

10. Anatomy Overview

11. Anatomy Overview Semicircular Canals The vestibular labyrinth consists of three fluid-filled semicircular canals oriented at 90° to each other, representing all three planes of space Herdman & Tusa, 2004

12. Anatomy Overview • Ampulla – dilated end of each canal that houses a mound of hair cells called the cristae ampullaris • The hair cells of the crista ampullaris project into the cupula, a gelatinous structure that seals the semicircular canal and is displaced with angular acceleration of the head

13. Anatomy Overview Jacobson, et. al., 1997 • Angular head movements cause movement of the endolymph within the semicircular canals, placing pressure on the cupula • Hair cells embedded in the cupula send excitatory or inhibitory signals depending on the direction of the fluid displacement

14. Anatomy Overview Ampullopetal vs. ampullofugal displacement

15. Anatomy Overview Utricle and Saccule • Linear accelerometers oriented vertically (saccule) and horizontally (utricle) in the vestibule of the labyrinth • Hair cells are embedded in the maculae and covered with the otolithic membrane

16. Central Vestibular System • Information from the hair cells in the semicircular canals is sent to the vestibular nuclei • Second order neurons transmit signals through the medial longitudinal fasciculus to the third, fourth, and sixth oculomotor nuclei

17. Central Vestibular System • Third order neurons innervate the extraocular muscles • The muscles are responsible for making eye movements equal to and opposite head movement • Basis for the vestibuloocular reflex (VOR) Herdman & Tusa, 2004

18. Mechanisms underlying BPPV Dislodged otoconia from the utricle settle in a semicircular canal causing overexcitability with angular head movements How do the otoconia become dislodged?

19. Causes of BPPV • Primary or idiopathic BPPV • Head trauma • Vestibular neuritis • Viral labyrinthitis • History of inner ear pathology • History of otologic surgery • Migraines

20. Mechanisms underlying BPPV Canalithiasis vs. Cupulolithiasis

21. Mechanisms underlying BPPV Herdman & Tusa, 2004 Canalithiasis Delayed onset Short duration Symptoms coincide with nystagmus

22. Mechanisms underlying BPPV Cupulolithiasis Typically not delayed onset Long duration Symptoms may stop Herdman & Tusa, 2004

23. Posterior Canal BPPV • Characterized by brief attacks of rotary nystagmus caused by head movements • Rolling over in bed • Looking up/down • Bending forward • Sitting up • Lying down • Turning quickly

24. Posterior Canal BPPV • Most common variant • Position relative to vestibule • Canalithiasis more predominant • Diagnosed using the Dix-Hallpike Maneuver • Best seen with Frenzel lenses or Videonystagmography

25. Posterior Canal BPPV • Typically, the nystagmus beats toward the undermost (affected) ear • As seen by the investigator • Abnormal Dix-Hallpike maneuver to the right will result in nystagmus with a counter-clockwise fast phase • Abnormal Dix-Hallpike maneuver to the left will result in nystagmus with a clockwise fast phase

26. Posterior Canal BPPV Diagnostic criteria • Latency • Duration • Linear-rotary nystagmus • Reversal • Fatigability

27. Anterior Canal BPPV • Least common variant – 1-2% • Diagnosed using Dix-Hallpike Maneuver • Characterized by downbeat rotary nystagmus • Can be provoked from the opposite ear to the side of the Dix-Hallpike maneuver • Can be provoked from the Dix-Hallpike maneuver from either side or head-hanging back position • Due to orientation of anterior limb of the anterior canal (near saggital plane) • Will typically beat toward the affected ear

28. Horizontal Canal BPPV • Approximately 3-12% of individuals with paroxysmal positioning vertigo • Diagnosed by positional test or Roll test

29. Horizontal Canal BPPV • Characterized by short latency horizontal nystagmus that is provoked by bilateral head turns • Prolonged duration and poor fatigability • Nystagmus can be seen in both lateral right and lateral left positions • Geotropic nystagmus - “bad” ear typically has the strongest response • Ageotropic nystagmus – “bad” ear typically has the weaker response (inhibitory response)

30. Horizontal Canal BPPV Nystagmus can be geotropic or ageotropic • Geotropic – canalithiasis • Otoconia move freely in the canal to the lowest position (toward the ampulla) causing an excitatory response with the affected ear down

31. Horizontal Canal BPPV • Ageotropic – cupulolithiasis • Otoconia are adherent to the cupula causing gravity sensitivity and an inhibitory response with the affected ear down • Nystagmus will beat toward the uppermost ear

32. Right Horizontal SCC Herdman & Tusa, 2004

33. Mixed Canal BPPV BPPV can affect more than one semicircular canal resulting in varying patterns of nystagmus • Posterior and horizontal canals most common • Simultaneous posterior and horizontal canal BPPV

34. CASE STUDIES

35. HB • 41 year old female • Three month hx of dizziness when tilting head to the right • Dizziness • lasts approximately 5 seconds • occurs with turning head to right, tilting head, getting up quickly • Pt. has 2 bulging discs in neck

36. HB • Physical exam • Audiologic evaluation • Prior MRI

37. HB – Head-Hanging Right

38. HB – HHR repeat

39. HB – Post Treatment

40. MP • 51 year old female • Fell off bicycle – loss of consciousness • Helmet cracked – fractured L temporal bone, shoulder, and ribs • L inner ear structures appeared normal • Small intracerebral bleed

41. MP • Complains of mild vertigo when leaning backward or lying down • Dizziness passes quickly • Muffled hearing on left side • Pt. had blood in left ear canal, middle ear, and mastoid • Treated with prednisone

42. MP 1 month later • L middle ear clear, but hearing still muffled • Persistent vertigo – lasts for seconds • Audiogram showed improvement in L hearing • VNG ordered

43. MP – Head-Hanging Right

44. MP – Head Hanging Left

45. MP – HHR repeat

46. MP – Post Treatment

47. MP – Post Treatment • Two days later – c/o different form of dizziness • Patient denied any side-lying • Dizziness ranges from 5 to 8 on scale of 1 to 10 • Four days post treatment

48. SM • 56 year-old male • Complains of intermittent dizziness • Left Dix-Hallpike Maneuver • Downward and leftward torsional nystagmus after 5 seconds • Right Dix-Hallpike Maneuver • Upward and rightward torsional nystagmus with severe vertigo • When returned upright nystagmus changed to downbeat torsional

49. SM • Involvement of right posterior and left anterior semicircular canals? • Central lesion?

50. Summary • BPPV is easy to diagnose and treat • Take an active role in the diagnosis and treatment of dizziness • Know your limitations • Multidisciplinary approach