1. BENIGN PAROXYSMAL
POSITIONAL VERTIGO

2. Basic Anatomy

3. BPPV
Barany 1921
Dix-Hallpike 1952 – important features
of nystagmus
Abnormal sensation of motion elicited
by certain critical positions
Provocative position  nystagmus
At least 20% of vertigo
Underestimated

4. BPPV …
Subclassification : scc post/lat/ant/bilat
Pathophysiology :
– Canalithiasis
– cupulolithiasis

5. Pathophysiology

6. Pathophysiology (cont.)
Cupulolithiasis :
– Harold Schuknecht 1962
– Densities (otocania) adherent to cupula of
crista ampullaris
– Basophilic particles -1969

7. Canalithiasis :
– John Epley – 1980
– Densities free floating in canal portion
– Parnes , McClure – 1991 found particles in
post SCC

8. BPPV ...
Frequency : 10-64/100000
Sex : 64% women
Age : older population ( 51-57)
younger than 35 – head trauma.
History :
– sudden
– days-weeks
– occassionally months -years
– episodes.

9. Physical :
– neurological examination – normal
– except – Dix-Hallpike  pathognomonic

10. BPPV …
Nystagmus : characterization and types
– RT / LT , vertical / horizontal , changing
– Tortional = Rotational – clockwise /
counterclockwise
– Geotropic- toward the earth
– Ageotropic – opposite

11. BPPV …
Classic post SCC – geotropic rotatory
nystagmus
Horizontal SCC – purely horizontal
nystagmus
Non-fatiguing nystagmus –
cupulolithiasis > canalithiasis

12. Classic BPPV
Involved the POST SCC
– Geotropic NG with affected ear down
– Rotatory , fast phase toward the undermost
ear
– Latency – few seconds
– Duration – limited < 20 seconds
– Reversal upon return upright position
– Response decline upon repetitive
provocation

13. Lat. SCC PPV
Most common atypical BPPV
3-9% of cases
Consequence of Epley maneuver
Horizontal purely nystagmus
Cupulolithiasis rather than canalithiasis
Modified Epley / lampert maneuver …

14. Lat. SCC PPV

15. Ant. SCC PPV
Rare – 2%
Down-beating /torsional NG for the
opposite ear on Dix-Hallpike maneuver

16. BPPV - Causes
Predisposing factors :
– Inactivity
– Acute alcoholism
– Major surgery
– CNS disease

17. Causes ( cont. )
Idiopathic – 39%
Ear disease – 29%
– OM – 9%
– Vestibular neuritis – 7%
– Menier’s dis – 7%
– Otosclerosis – 4%
– Sudden SNHL – 2%
Trauma – 21%

18. Causes ( cont. )
Trauma – 21%
CNS diseases – 11%
Acustic neuroma – 2%
Cervical vertigo – 2%

19. BPPV - D.D
Menier’s disease
Inner ear concussion
Alcohol intoxication
Labyrinthitis
Vascular loop syndrome
Post. Fossa lesions : acustic neuroma ,
meningioma
Central origion : stroke , MS , cerebellar
degeneration
Vertibral artery insuffeciency
Cervical vertigo

20. BPPV - Treatment
Watchful waiting
Vestibular suppressant medications
Vestibular rehabilitation
Canalith repositioning
Surgery care
– Labyrinthectomy
– Post. Canal occlusion
– Singula neurectomy
– Transtympanic aminpglycoside application

21. Trials about BPPV

22. General
Labeled benign paroxysmal positional
vertigo is not always benign
Evaluation of the effectiveness of
canalith reepositioning procedurs –
CRP
Several studies …

23. Trials …
Blakely – 1994 :
– 50% improvement in the control and CRP
group !! ( 2-3 months)
Lynn – 1995 :
– Randomized-controlled : 89% negative DH
in CRP group , 27% in the control group
John Li (1995) :

24. Trials…
John Li (1995) :
– Comparison CRP / CRP + mastoid oscillation and
control
– Modified Epley maneuver
– Use of colar and head elevation after CRP
– No spontaneous resolution within aweek
– 60% symptoms improvement in CRP group
– 92% symptoms improvement in CRP +mastoid
oscilation and 70% negative DH

25. Trials…
R. steenerson –1996 :
– Comparison of CRP and vestibular
habituation training
– Tow approaches are effective in
symptomatic relief ( 3 months)
– CRP faster relief and fewer treatments

26. Trials …
K. Yimatae (2003)
– Randomized-controoled
– Modified Epley maneuver, no mastoid oscillator
and no instructions after the maneuver
– Subjective and objective weekly follow-up
– CRP group – 76% negative DH, 48% control group
– CRP group – 96% symptoms improvement , 90%
control group
– Non-cured patients need > 6 procedures in 2
weeks , should considering liberatory maneuver

27. Elderly population and BPPV
S. Angeli – 2003 :
– Effectiveness of CRP and VR
– Modified Epley :
Elderly comorbidities : degenerative osteoarthritis
disease , CVA , peripheral neuropathy, cognitive and
autonomic dysfunctions
S/E of CRP – neck torsion and extension result in
vertibrobasilar artery insufficiency, strain on the spine
column, dislodged carotid a. emboli
Avoid liberatory maneuver
– 64% CRP group – negative DH after a month
– Overall 77% with CRP and VR

28. CRP Meta-Analysis
B. Woodworth - 2004
CRP - First line of treatment
– Non-invasive
– Easy to perform in the office
– No need to expensive instrumentations
– Repeat maneuver if needed
– Potential to provide rapid relief of vertigo

29. Meta - Analysis
9 randomized-controlled trials
Symptoms resolution and elimination of
positive Dix-Hallpike test
CRP more effective than control ( x5 )
Untreated patients - symptoms
improvements with time but positive DH
So Resolution of vertigo – avoidance of
provocative positions

30. CRP – Epley maneuver

31. CRP – Semont maneuver

32. Mastoid oscillator

33. Brandt-Daroff Exsercise

34. Lampert maneuver- Lat. SCC
BPPV

35. Vestibular rehabilitaions

36. Complications of CRP
Failure – 25% (12%-56)
Recurrence – 13% in 6 months
Side effects
– Nausea
– Vomiting
– Fainting
– Sweating
Worse vertigo – LAT SCC PPV

37. THANK YOU …