BPPV talk3

7/29/2019 BPPV talk3

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Diagnosis & Treatment of BPPV Is Not

Always Easy Two More Demanding CaseStudies.

Dr John E FitzGerald

Consultant Clinical Scientist

Norfolk & Norwich University Hospital


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Benign Paroxysmal Positional Vertigo

(BPPV)- The Condition

Cause:Otoconia from the

gelatinous membrane of the

utricle or saccule in the

vestibular labyrinth of theinner ear, break free and

reach the semicircular canals

(most commonly the

posterior semicircular canal(Lanska and Remler, 1997).


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Benign Paroxysmal Positional Vertigo

(BPPV)- The Condition

Certain position changes cause

otoconia in the endolymphof the semicircular canal tomove, resulting in ahydrodynamic drag effect,causing the cupula to bedisplaced, resulting in achange in neural firing rate,inducing a true rotationalvertigo. (Canalithiasis hall

et al, 1979).

The subject feels a shortduration dizziness.


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Diagnosis

Presenting Symptoms

Short duration rotational vertigo when adopting specific

positions, (rolling to the affected side in bed, rising frombed in the morning, looking up, lying down)

Vertigo is of latent onset (however this may not always

be noted by the patient)

Vertigo adapts if the position is maintained


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DiagnosisA Positive Hallpike Manoeuvre

Rapidly move patient from a sitting position, with their head turned 45 to theright or left, to a lying position with the head tipped 45 below the horizontal

A classical positive response is defined as

a latent period before the onset of nystagmus;

geotropic rotatory nystagmus with adaptation within 40 seconds (anupbeating vertical component is also sometimes evident)

reversal of nystagmus on sitting up (not always evident)

fatiguing of response on repeated manoeuvres

duplication of the patients report of vertigo. A positive response is attributed to the under most ear


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Positive Response


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Case 1.

A 56 year old manReferred by GP with a 6 month history of

dizzy spells, especially when he puts his

head back

Seen in January 2003 for vestibular

assessment


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Symptoms:

Off work for several months

TRV lasting 20seconds provoked by lying

supine, rising from the supine, rolling left orright in bed.

Last occurred morning of test.Left sided headaches, started at same timeas dizziness (respond to headache tablets).


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Hallpike Manoeuvre:Right: Positive

Latent onset geotropic rotatory nystagmus with associated dizziness,adapted after approx. 10seconds BUT followed by an ageotropicrotatory nystagmus for a further 30seconds at least. On rising avertical nystagmus was observed but this adapted.

On repeat only a geotropic nystagmus was present which adaptedand associated with less marked dizziness

Left: Positive

Latent onset more prominent geotropic rotatory nystagmus,showed adaptation after 60 seconds. Very dizzy and nauseous.

Complete fatigue on repeat.


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Conclusion:

Bilateral BPPV, worse on the left ear

Due to nausea only a Left sided Epley was

performed


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1 week post treatment reviewConsiderable improvement on rising from bed

Headaches diminished

BUT dizziness still provoked by some movements

ENG No spontaneous or gaze evoked nystagmus.

Normal Smooth Pursuit & saccadic following

Hallpike Manoeuvre: Left Positive

Latent onset less prominent than previous week geotropic rotatory nystagmus,

showed adaptation after 30 seconds. Dizzy.

RightPositive Latent onset geotropic rotatory nystagmus with associated dizziness, BUT NO

ageotropic rotatory nystagmus this week.

Due to nausea the left Epley was conducted immediately from the supine position of the

Hallpike.

Right Epley also performed.


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Further Reviews

3 weeks post treatment Symptoms continue

Headaches returned

Positive Hallpikes left and right

Breathless on rising from right Hallpike reported breathlessness on walking Worries about losing job

Further left Epley performed, referred for MRI to investigate

central pathology and advised to seek cardiovascular and

respiratory investigations (weight gain noticed).

Referred back June 03

Diagnosed chronic obstructive airways disease (under treatment)

Normal MRI (of IAMs)


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Further ReviewsReviews June 2003 - Sept 2003

Dizziness induced by rolling to left side, looking up, rising frombed in morning. Feeling of loosing consciousness & sometimes

wooziness lasting all day.

Right Hallpike: Classic positive findings.Left Hallpike : Negative.

Repeat Right Epley Manoeuvres (x 3 occasions).

Brandt Daroff Exercises.Discharged accepting some improvement, but no complete

recovery.


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Case 1 Right Hallpike (June 2004)

10 Second latent onset

AGEOTROPIC

rotatory nystagmus

Duration 20 secondsOn rising Nil

Testing stopped due tonausea

Eyes Up

Patient Eyes left Patient Eyes Right

Eyes DownN.B. Image is a mirror reflection of patient


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Take a Valium!

5mg 2 hours before appointment

5mg before being seen

Advice on driving!


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Case 1 Right Hallpike (Sept 04)Latent Onset

Short duration dizziness

? Horizontal Nystagmus

?Vertical Nystagmus

Geotropic rotatory

nystagmus

Adapts within 20seconds

Eyes Up

Patient Eyes left Patient Eyes RightEyes Down

N.B. Image is a mirror reflection of patient


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Case 1 Right Hallpike

Geotropic rotatory

nystagmus

Adapts

On RisingDownbeating vertical

nystagmus

Adapts

Eyes Up


Eyes Down



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Case 1 - ConclusionsNystagmus is of a peripheral origin

Latent OnsetAdaptationPartial Fatigue

Reversal from upbeating to downbeating onrising

Where are the otoconia?

Posterior canal?

Horizontal Canal?

Anterior Canal?


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Case 2 - History

A 71year old lady

2 year history of TRV lasting seconds

Provoked by turning in bed either side,

sitting up, looking up, and general head

movements

Latent onset reported


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Case 2. Left Hallpike - down

Geotropic rotatory

nystagmus

BUT NO adaptation

after at least 80seconds

Eyes Up


Eyes Down



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Case 2. Left Hallpike - Up

Vertical downbeating

nystagmus

BUT NO adaptation

Eyes Up


Eyes Down



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Case 2. Right Hallpike - DownAGEOTROPIC

rotatory nystagmus

No adaptation within

60secondsLatent onset

Eyes Up


Eyes Down



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Case 2. Right Hallpike - UpVertical Downbeating

Nystagmus

NO ADAPTATION

Eyes Up


Eyes Down



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Test IndicationsCentral Pathology

Why?

Lack of adaptation of geotropic rotatorynystagmus in left Hallpike

Ageotropic rotational nystagmus in right Hallpike

with lack of adaptation.Maintained downbeating nystagmus on rising

from both sides


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Case 2 Other Test ResultsDownbeating vertical spontaneous nystagmus

Also present with left gaze, and down gaze

Enhanced with rightward gaze

Abolished with upward gaze

Caloric test: Balanced warm water irrigations

MRI: No CPA LesionVentricles normal size and shape, not

displaced. No intra-cranial abnormality


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Case 2 Possible IndicationsCentral Problem

Lower Medullary

Infarction (due to

enhancement ofdownbeating

vertical nystagmus

with lateral gaze,and abolition on

upward gaze)


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Summary

Consider Valium to help complete tests andpossible treatment.

Look for reversal of nystagmus on changingposition

Other tests should always be used in conjunction

with Hallpike Manoeuvre when nonstandardresults obtained

Cant treat everyone

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