1. Benign Paroxysmal Positioning 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. Ampullopetal vs. ampullofugal displacement
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 L middle ear clear, but hearing still muffled
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

51. References
Goebel J. (Ed.) (2001) Practical Management of the Dizzy Patient. Philadelphia: Lippincott Williams & Wilkins.
Hain, T. (2007) Anterior Canal BPPV.
Herdman SJ, Tusa RJ. (2004) Diagnosis and Treatment of Benign Paroxysmal Positional Vertigo, Schaumburg: GN Otometrics.
Jacobson G, Newman C, Kartush J. (Ed.) (1997) Handbook of Balance Function Testing. San Diego: Singular Publishing Group, Inc.
Parnes L, Agrawal S, Atlas, J. (2003) Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ, 169 (7),