BPPV Benign Paroxysmal Positional Vertigo By Wendy Carender, PT, NCS Advanced Vestibular Certified Physical Therapist

Disclosure Statement I have no relevant financial or nonfinancial relationships to disclose.

Team of Audiologists at UMHS Audiologists in Vestibular Testing Center Assist in the Identification of BPPV: Dix-Hallpike and Positional Testing during VNG Assist in the Management of BPPV Perform particle repositioning maneuvers for simple cases Patients are referred to Vestibular PT and/or Otolaryngologist for additional treatment and diagnosis.

BPPV ( Positional Vertigo) Benign: not life threatening, however symptoms may be intense Paroxysmal : occurs suddenly Positional: provoked by change in position of the head Vertigo: sense of rotation or spinning usually lasting less than one minute

BPPV Most common peripheral vestibular disorder 2.4% of all people will experience BPPV at some point in their lifetime ( Fife TD, Inversion DJ, Lempert T. Neurology 2008) Causes approximately 50 % of dizziness in older adults ( Froehling DA, Silverstein MD, Mohr DN. Mayo Clinic Proc 1991) Increased risk of falling Enormous Health Care Burden Estimated $2 billion per year Easy to diagnosis and treat at the bedside

BPPV Causes Primary cause in people over age 50 is idiopathic Primary cause in people under age 50 is head injury Increase frequency of BPPV found in patients with Migraine, Vestibular Neuritis and Meniere’s Disease BPPV occasionally occurs following other ear surgery (stapedectomy) (AtacanE, Sennaroglu L, Dene A. Laryngoscope 2001) BPPV may develop after long periods of inactivity

BPPV History History most important part of Vestibular Exam First episode typically provoked by rolling over in bed or getting out of bed 4 questions on Dizziness Handicap Inventory that are helpful to screen for BPPV - Looking up cause dizziness - Getting in/out of bed - Rolling over in bed Bending over

BPPV Anatomy Vestibular organ: 3 semi-circular canals, utricle and saccule. Semi-circular canals: detect rotational movements and are filled with endolymph Ampulla: One end of each semicircular canal is widened to form an Ampulla Cupula: sensory receptor located within the Ampulla 2 otolith organs measure linear acceleration and detect head tilt Utricle (horizontally aligned) contains otoconia Saccule (vertically aligned)

Anatomy of the Inner Ear Source of figures: Furman JM, Cass SP. Vestibular Disorders: A Case Study Approach, 2nd ed., © 2003.

Picture of Otolithic Macula

Otoconia Otoconia: calcium carbonate crystals that are attached to the otolithic membrane in the utricle BPPV occurs when otoconia detach from the utricular membrane and migrate into the semi-circular canals. Head movement otoconia shift endolymph flow cupular deflection false signal to brain vertigo and nystagmus.

Direction of Endolymph Flow is Important Ampullopetal flow = flow towards ampulla (to seek) In the horizontal SCC, this is excitatory. In the vertical canals, this is inhibitory. Ampullofugal flow = flow away from ampulla (to flee) In the horizontal canal, this is inhibitory. In the vertical canals, it is excitatory. So, how does movement of the otoconia within the SCC’s trigger vertigo ? Why does posterior canal BPPV have a different pattern of nystagmus compared to LSC-BPPV? To understand this, we need to review some basic principles regarding SCC’s anatomy and physiology. Who 1st described SCC anatomy (not physiology) – See Lustig’s hx articles… Discuss concept of endolymph drag vs particle pushes endolymph forward (endolmyph moves in direction particle moves) Much of following info taken now from Baloh + Honrubia, 2nd ed, pg 34: These principles were first elucidated during the 19th century, by Julius Richard Ewald, a German physiologist. In 1892 Ewald, published his findings on a series of experiments in pigeons designed to understand SCC function. He established clear relationships between the planes of the SCC’s, the direction of endolymph flow, and the direction of induced eye and head movements. Ewald surgically exposed the membraneous portion of the SCC’s in pigeons, and applied positive and negative pressures to each canal membrane to cause ampullopetal and ampullofugal endolymph flow (need to hve explained those 2 terms by now or at this point…). He made 3 important observations, which are now known as Ewald’s laws. His 1st law states that stimulation of a semicircular canal produces eye movements in the plane of the canal, as well as in the direction of endolymph flow. This law helps to explain the nystagmus patterns observed with different canal variants of BPPV. His 2nd law: Note that Carey writes in Cummings: Rather than memorize ampullopetal and ampullofugal stuff, “one need only recall that a SCC is excited by rotation in the plane of the canal, bringing the head towards the ipsilateral side.

Ewald’s Observations on Semi Circular Canal Function Eye movements occur in the plane of the SCC being stimulated AND in the direction of the endolymph flow In the vertical canals, ampullofugal endolymph flow canals causes a greater response (eye movements) than ampulopetal flow In the horizontal canals, ampullopetal endolymph flow causes a greater response than ampullofugal flow

Connections of SCCs with Extraocular Muscles Figure source: Baloh RW, Honrubia V. Clinical neurophysiology of the vestibular system, 2nd edition. Philadelphia, PA: F.A. Davis Company; ©1990.

slow-phase fast-phase Patterns of nystagmus associated with excitation of individual semicircular canals slow-phase fast-phase Left posterior Left superior Left lateral up-counterclockwise Fast-phase column Written to describe from pt’s perspective… Nystagmus has a slow component generated by the vestibular system and resetting quick phase generated by the saccade system. Nystagmus is named for the quick (fast) phase. down-counterclockwise left-beating Medical Illustration Copyright © 2009 Nucleus Medical Art. All rights reserved. www.nucleusinc.com

2 Types of BPPV Canalithiasis Most common form of BPPV Otoconia float freely in endolymph Latency (2-30 sec) in onset of vertigo and nystagmus after the patient moves into the provoking position Fluctuation in intensity of vertigo and nystagmus, with a typical crescendo-decrescendo pattern, which resolves within 60 seconds.

2 Types of BPPV Cupulolithiasis Not as common Otoconia adhere to the cupula Immediate onset of vertigo and nystagmus when the patient moves into the provoking position Persistence of vertigo and nystagmus as long as the patient remains in the provoking position (> 60 sec) Important to differentiate between canalithiasis and cupulolithiasis to help guide your choice of treatment

Canal Involvement Prevalence of BPPV (Fife and Lempert 2008) Posterior canal: 81-89% Horizontal/Lateral canal: 8-17% Superior/Anterior canal: 1-3% of cases Video goggles used to record eye movement: (Imai et al 2005, Lopez-Escamez, et al 2005) Posterior Canal: 41-65% Horizontal canal: 21-33% Superior canal: 17% Multi-canal: 20% Common following head trauma. Use Goggles for accurate diagnosis!

Dix-Hallpike Test (Barany Maneuver) 1952- Margaret Dix, MD and Charles S. Hallpike, MD Gold standard test for diagnosis of posterior semi-circular canal BPPV Contraindications: severe RA, recent neck trauma or neck surgery, vertebral basilar insufficiency, Chiari Malformation Infrared Goggles to record eye movements or room light To perform the Dix-Hallpike test, begin with patient long sitting on the treatment table with head rotated 45◦ right or left, then quickly go to supine with head hanging slightly off the table (20◦ extension). Repetition of Dix-Hallpike results in fatigue of nystagmus

Picture Dix-Hallpike Test

Picture of Sidelying Test To test the right ear, turn patient head 45 ⁰ to the left side and have them quickly lay down on their right shoulder. Wait at least 30 seconds for any nystagmus to appear.

Pattern of Nystagmus for Positive Dix-Hallpike Vertical Component Upbeating: posterior canal Downbeating: anterior canal or possibly central Torsional Component (named from patient perspective) Right Hallpike: right torsion, clockwise, beating towards the dependent right ear Left Hallpike: left torsion, counter clockwise, beating towards the dependent left ear Horizontal Component: horizontal canal, perform Roll Test Duration Less than 60 seconds: Canalithiasis Greater than 60 seconds: Cupulolithiasis Return to sitting: pattern of nystagmus reverses

Right Dix-Hallpike Video

Left Dix-Hallpike Video

Left Dix-Hallpike Video

VNG testing to diagnosis BPPV Do NOT rely on the tracings for accurate diagnosis of Posterior or Anterior Canal BPPV! -Vertical channel: direction of nystagmus is accurate. -Horizontal channel: cannot correctly identify the direction of the torsional component of nystagmus (Vanderheyden, Heidenreich, Carender 2013 pre-publication) Focus on video to correctly identify the torsional component of the nystagmus.

Do NOT use tracings to diagnose BPPV

Right Dix-Hallpike Video During VNG Testing

Left Dix-HallpikeTracing

Left Dix-Hallpike Video During VNG Testing

BPPV Treatment options: Particle Repositioning Maneuvers (PRM): 75-80% success rate in treating posterior canal BPPV in one office visit. Modified Epley (Canalithiasis) Liberatory/Semont (Cupulolithiasis) Brandt-Daroff Habituation Exercises. Watch and wait: otoconia dissolve over time. Caution patient to avoid provoking positions due to increased fall risk Surgery: posterior canal plugging. Medication: Vestibular Suppressants (Meclizine, Valium) are typically not helpful since this is a “mechanical problem”.

Treatment options-Maneuvers Semicircular Canal Involvement Canalithiasis nystagmus< 60 seconds Cupulolithiasis nystagmus> 60 seconds Posterior- upbeating torsional nystagmus -Modified Epley (Particle Repositioning Maneuver) -Liberatory Maneuver -Liberatory Maneuver (mastoid vibration) -Brandt-Daroff Exercises Anterior- downbeating torsional nystagmus -Liberatory Maneuver modified for AC -Reverse Epley -Liberatory Maneuver AC (mastoid vibration) Horizontal- horizontal geotropic or ageotropic nystagmus -Lempert 360 BBQ Roll -Appiani (modified Liberatory) -Forced Prolonged Positioning - Casini (Modified Semont) -Brandt-Daroff modified for Horizontal Canal

Modified Epley Maneuver (Left Ear) Wait dizziness PLUS 30 seconds in each position. Eye movements should remain ipsi-torsional throughout the maneuver. 180⁰ rotation of the head is required to effectively clear the debris (position B to D)

Video of Epley Maneuver-Home Version

Guidelines for a Successful PRM Each position must be held a minimum of 30 seconds to allow the particle to settle ( Hain et al, 2004). Perform at least 2 maneuvers within the treatment session to optimize outcome. Wait at least 2 minutes in-between maneuvers. Only treat one ear, one canal at a time (24 hour period) Activity Restriction: patients without activity restrictions required more treatment sessions (Cakir, et al 2006) Sit for 15 minutes with head level in the clinic Avoid bending over or laying flat the rest of the day (can sleep in regular position at night)

Liberatory/Semont Maneuver for Treatment of Posterior Canal BPPV (Cupulolithiasis Variant) Treatment shown for right posterior canal Turn head 45° away from the affected side (left) Quickly lay on affected side (right) and wait 1 minute Quickly move the patient to opposite sidelying (< 1.5 seconds) without changing the head position and wait for 1 minute Slowly return to sitting with the head level Figure source: Parnes LS, Agrawal S, Atlas J. Diagnosis and management of BPPV. CMAJ 2003;169(7):681-693.

Video for Liberatory/Semont Maneuver

Additional Recommendations for Treatment of BPPV Patient with bilateral posterior canal BPPV: treatment of choice is Liberatory Maneuver to avoid triggering excessive nausea. Treat one ear per session. Treatment for severe nausea: Zofran or Compazine prior to maneuvers. Use tilt table if patient has limited cervical extension. Cupulolithiasis not responding to maneuvers: add mastoid vibration for 20 seconds in each position during maneuver. Canal Conversion during PRM: 6% risk of conversion from posterior to horizontal canal during the particle repositioning maneuver.

Brandt-Daroff Habituation Exercises Not as effective as repositioning maneuvers (Cohen HS, Kimball KT. OtolNeurotol 2005;26: 1034-1040)) Mechanism dislodges otoconia debris from the cupula otoconia dissolve in endolymph central adaptation occurs so patient less symptomatic 5 Repetitions, 2x/day for 2 weeks Figure source: Google Images

Supine Roll test for Horizontal Canal BPPV Supine Roll Test: tested in tranverse plane along the longitudinal axis of the body with head elevated 20-30⁰ 0° neck flexion Figure source: Heidenreich KD, Carender WJ, Heidenreich MJ, Telian SA. Annals of Vascular Surgery 2010; 24(4):553.e5.

Roll Test for Horizontal Canal BPPV Roll Test is used for horizontal canal BPPV. Patient is supine with the head flexed 20°. Head is quickly turned to one side for 60 seconds and nystagmus is observed. Return to head center position and wait a few seconds. Then the head is quickly turned to the other side for 60 seconds. If the patient does not have full cervical rotation, then have the patient quickly roll onto their right or left sides. Similar to Head and Body Right/Left Positional Testing If horizontal nystagmus during the Hallpikes OR Hallpikes are negative and BPPV is suspected based on history, then perform the Roll Test

Horizontal/Lateral Canal BPPV Lateralization of Side of Involvement Positive Roll Tests = horizontal nystagmus and vertigo would occur when the head is turned to both sides due to the co-planar orientation of the canals Geotropic (towards the earth) Nystagmus: debris located in the long arm of the horizontal canal side of greatest intensity is the affected lateral canal Ageotropic (away from the earth) Nystagmus: debris attached to the cupula OR otoconia lie close to the ampulated end of the canal. side of lesser intensity is the affected lateral canal

Left Geotropic Horizontal Canal BPPV Geotropic HSC BPPV is due to canalithiasis where the otoconial debris lies far away from the ampullated end of the canal. If patient performs a lateral head turn toward the affected ear, the particles will create and ampullopetal endolymph flow which is stimulatory in the lateral canal. A geotropic nystagmus, fast phase toward the ground will be present. Patient turns away from the affected side, particles create and inhibitory ampullofugal flow. Nystagmus is in the opposite direction, but patient is now on the other side so the nystagmus will remain geotropic. Ewald 2nd Law: response to an excitatory stimulus is always more intense than that observed with an inhibitory response. In left ear down position, there is ampullopetal migration of otoconia. This is excitatory in the left HSC and pt develops a Left Beating nystagmus. In right ear down position, there is ampullofugal migration of otoconia. This is inhibitory, and the pt develops a Right Beating nystagmus. Figure courtesy of J.A White, MD, PhD

Roll Test- Horizontal Nystagmus

Treatment of Geotropic Horizontal Canal BPPV Right Ear-Lempert BBQ Roll 270⁰ -vs- 360⁰ log roll- 30 seconds in each position Use caution to avoid over rotation with the 360° maneuver!

Video BBQ Roll Maneuver-Home Version

Modified Libertory maneuver (Appiani) for Horizontal Canalithiasis (Geotropic) Patient begins with head in a neutral position and quickly lies down on the unaffected side and waits for one minute. Patient turns head 45 degrees downward and waits for one minute. Patient slowly returns to sitting with their head level. Treatment show is for the LEFT ear Photo from Herdman 2007

Conversion of Ageotropic Nystagmus to Geotropic Nystagmus in Horizontal Canal Head Shaking (Vanmicci et al 1992) 20 head oscillations in the horizontal plane with the patient supine and head tilted 30⁰ forward Rapid Rolling (Lempert 1994) Rapidly roll from side to side 10 times. Head Pitching ( Califano, et al 2008) Pitch head 60⁰ forward and 45⁰ backward 20 times.

Modified Semont (Casini) for Horizontal Canal Cupulolithiasis (Ageotropic ) Patient moves quickly from sitting with head in neutral to sidelying on the affected side. Head is immediately turned so the nose is down 45⁰. Patient stays in this position for 2 minutes, then slowly returns to sitting. Treatment shown for the right ear Photo from Herdman 2007

Factors Contributing to Recurrence Rate of recurrence is 15% per year, cumulative. Rate of recurrence may be as high as 25% in the first year, 44% in second year (Hain, Helminski, 2000) Factors contributing to recurrence: Head Trauma A daily routine of Brandt-Daroff Exercise or Epley maneuver does not affect the time to recurrence or the rate of recurrence. Helminski JO, JanssenI, Hain TC. Otol & Nerotol 2008;29:976-981.

Clinical Practice Guidelines: BPPV Otolaryngology-Head and Neck Surgery 2008 Recommended against full vestibular testing or radiographic imaging in “routine” cases. Dix-Hallpike and Positional Testing with Videogoggles would be indicated if BPPV is suspected. Recommend against treatment with vestibular suppressants like benzodiazepines or antihistamines. Recommend clinicians reassess BPPV patients within one month of treatment to confirm resolution.

Case Study 1 -History 47 yo female with daily episodes of vertigo triggered by reclining back in bed. Vertigo was particularly severe when lying on her left side. It did not respond to a trial of Brandt-Daroff Habituation Exercises recommended an outside PT. Based on this history, would you suspect BPPV?

Case Study 1 -Exam Findings No spontaneous or gaze nystagmus in room light Normal pursuits and saccades No spontaneous or post head shake nystagmus with fixation removed using infrared goggles Gait was steady

Persistent Positional Nystagmus: A Case of Superior Semicircular Canal BPPV. Heidenreich, Kerber, Carender 2011

Modified Liberatory Maneuver

Case Study 2 - History 54 yo male sudden onset of vertigo, nausea, vomiting and imbalance lasting 24 hours. He then experienced brief episodes of positional vertigo and nausea when lying down or rolling over to both directions in bed. Based on this history, would you suspect BPPV?

Case Study 2 – Positional Testing Is this a positive Dix-Hallpike?

Positional Testing Reveals Ageotropic Pattern of Horizontal Nystagmus

Case 2- Horizonal Canal BPPV Head and Body Right and Left Positional testing: similar to Roll Tests that Physical Therapists use to identify Horizontal canal BPPV Horizontal Canal BPPV: video and tracings are both helpful for correct diagnosis

Case 2- Diagnosis of Horizontal Canal BPPV A) Right Horizontal Canal - canalithiasis B) Left Horizontal Canal – canalithiasis C) Right Horizontal Canal – cupulolithiasis D) Left Horizontal Canal – cupulolithiasis

Horizontal Canal BPPV Positive Roll Tests = horizontal, bidirectional nystagmus Geotropic (towards the earth) Nystagmus: side of greatest intensity is the affected lateral canal Ageotropic (away from the earth) Nystagmus: side of lesser intensity is the affected lateral canal

Vestibular PT Evaluation (later same day) Roll Tests in room light Right Roll: left beating horizontal nystagmus lasting > 60 seconds Left Roll: right beating horizontal nystagmus lasting > 60 seconds. Nystagmus appeared to be of equal intensity to both sides. Speed of the roll/head movement will affect the response! Patient was more symptomatic when rolling to the RIGHT side.

Case 2 –Vestibular PT Treatment Left Horizontal Canal-Cupulolithiasis 3 sessions of Vestibular PT combined with daily home program Resolved with Brandt-Daroff modified for Horizontal Canal combined with Casini Maneuver for the Left ear

Caloric Testing 73% Left Caloric weakness Otolaryngologist Diagnosis included: Vestibular Neuritis and Horizontal Canal BPPV involving the left ear

Thank You Margot Beckerman, Au.D., CCC-A, Assistant Director University of Michigan Vestibular Testing Center Crystal VanderHeyden, Au.D. Shaleta Harvard, Au.D.

References Herdman, S.  Vestibular Rehabilitation. 3rd Editiion. F.A. Davis Company 2007. www.vestibular.org Vestibular Disorders Association. Journal: Bhattacharyya, N, Baugh, R et al. Clinical practice guideline: Benign Paroxysmal Positional Vertigo. Supplement to Othlaryngology-Head and Neck Surgery.  Vol 139, November 2008. Heidenreich KD, Kerber KA, Carender WJ. Persistent Positional Vertigo: A Case of Superior Semicircular Canal BPPV? Laryngoscope, 121:1818-1820, 2011 http://www.youtube.com/user/UMHealthSystem#p/u

Questions? Please contact Wendy Carender, PT wcaren@med.umich.edu University of Michigan Vestibular Testing Center: 734-936-9420 Thank you!