Benign paroxysmal positional vertigo

Condition

• Benign paroxysmal positional vertigo (BPPV)

Definition 

• Common type of acute vertigo that is induced by changing head position - particularly tilting the head backwards, changing from a recumbent to a sitting position or turning to the affected side
• The underlying cause is unknown. Generally accepted theory of causation is that fine pieces of calcium carbonate present in the utricle and become loose, settle at the bottom of one o f the semicircular canal, and generate endolymphatic movement, causing nystagmus with certain head positions. 

History

• Occurs in clusters that persist for several days 
• Usually a latency period of several seconds following a head movement before symptoms develop, and symptoms subside within 10-60 seconds, usually fewer than 30 seconds. 
• Female to male ration is 2:1
• Attacks are not accompanied by vomiting, tinnitus or deafness (nausea may occur)
• Recurs periodically for several days 

Examination

• Normal hearing and vestibular function 
• Positive hallpike manoeuvre
• Brief latency - usually a brief latency of several seconds before the onset of nystagmus and it usually lasts 10-20 seconds
• Nystagmus - usually torsional but may be horizontal. 
• Reversal- upon sitting after a positive manoeuvre, the direction of nystagmus is reversed for a brief period of time
• Fatigability - repetition of the test will result in less nystagmus each time 
• Normal cranial nerve examination 

Murtagh's diagnostic triad

Treatment

• Re-assurance that this condition usually resolves spontaneously  
• Explanation of avoidance measures 
• Brandt-Daroff exercises (Table 1 from RACGP check program dizziness
• Epley manoeuvre 

• The patient sits on the bed with head slightly extended and turned 45 degrees in the direction that precipitated the vertigo 
• The patient then lies on their back with the head hanging over a pillow placed at the shoulder level 
• From this position, turn the head through 90 degrees to the opposite side and wait 1 minute
• Slowly sit the patient upright with the head in a neutral position and sit still for 10 minutes 

Reference:

• John Murtagh 5th ediation 497
• Check program RACGP 2011 Dizziness