1. Benign Paroxysmal Positional Vertigo
Managing the BPPV patient

2. Summary of Inner Ear Anatomy
Cochlea- sound
3 Semicircular Canals- sensitive to angular rotation
Cupula- hair cells sensitive to displacement of endolymph
Otolith- Saccule and Utricle sensitive to gravity and linear acceleration
Vestibular Nuclei- area(s) of brain where impulses travel from vestibularcochlear nerve (CN VIII)

3. Ear Anatomy
Brief discussion on SCC (3) Otolith (2) Endolymph and Cochlea. Very brief.

4. Utricle is sensitive to linear acceleration like nodding
Utricle is sensitive to linear acceleration like nodding. Saccule detects up and down motion like riding in a car or with walking. The calcium carbonate crystals are not called otoliths, they are otoconia.
Otoconia

5. What is BPPV?
Calcium carbonate otoconia separate from the gelatinous membrane of the otolith and migrate into the endolymph of the SCC.
Most likely migrates in the endolymph of the posterior canal called canalithiasis.
Positional change of the head allows the otoconia to migrate with gravity within the SCC.
Use the snow globe analogy.

6. Migration of Otoconia
Change in position of the head allows otoconia to move within the endolymph, spilling the otoconia like snow in a snow globe.

7. What is BPPV?
This migration displaces the hair cells in the cupula thus stimulating the inner ear.
Impulses relay to the vestibular nuclei, thus setting off the VOR in a specific pattern: brief, down/upbeating, torsional nystagmus.
Direction of nystagmus is consistent with the canal involved. Upbeating with the posterior canal, downbeating with the anterior canal.

9. Testing for BPPV: Dix Hallpike Maneuver: Right Side
Patient sits long sitting on a plinth.
Turn patient’s head 45 degrees to the right.
While holding your patient’s head, direct the patient to lie flat on his back.
Observe for nystagmus and note the direction of the beat, the torsion and the time.

10. Treatment for Anterior/Posterior Canal Canalithiasis: Canalith Repositioning Maneuver
Start with the Dix Hallpike to the affected side. Hold for up to 1 minute.
Gently rotate the head 45 degrees in the opposite direction. Maintain cervical extension. Wait up to 1 minute.
Instruct the patient to roll onto his side, assist by rotating the head to allow the patient to look down to the floor. Wait 1 minute.
Slowly assist the patient to sit at the edge of the plinth.
(Rainer 2017, Epley 1992)
For the scope of this discussion, we will discuss anterior/posterior canal canalithiasis. Additional BPPV can be found in several other areas including the cupula of the anterior and posterior canal as well as the endolymph and cupula of the horizontal canal. There are different treatments for this, but we can always try this maneuver.

11. Treating Left BPPV
Start with the Dix Hallpike left position. Wait 1 minute in between each position.

12. Post CRM Instructions to the Patient
Be sure to remain upright with head in a neutral position for most of the day.
Try to avoid cervical flexion/extension throughout the day.
Do not lie supine for most of the day.
The more the patient can follow these instructions, the better the chance for the otoconia to reabsorb into the membrane of the otolith.

13. Questions?