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Dr
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Patients with BPPV experience brief episodes of vertigo whenever the
head is in certain positions, although they may have a prolonged or constant
sense of unsteadiness at other times
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The vertigo usually begins around 5-10
seconds after the head assumes the symptomatic position
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The vertigo generally
becomes less severe if the head is placed in the symptomatic position several
times in a row
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The main symptom of BPPV is vertigo (spinning sensation) induced by a change
in head position with respect to gravity
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However, the symptoms of BPPV may vary among patients, and
may manifest with nonspecific dizziness, postural instability, lightheadedness,
and nausea (Blatt et al
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The vertigo in BPPV is typically intermittent and
positioning dependent
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Dix-Hallpike test
Start by having the patient sit near one end of the examination table, with the
body facing the far end of the table and the head turned 45 ° to one side
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Keep the patient in this position for at least 20 seconds and ask him/her to
report any symptoms of vertigo, while at the same time, you are observing the
patient’s eyes for nystagmus
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To establish the diagnosis of BPPV, one of these positions should trigger a
burst of upbeat and torsional nystagmus that lasts about ten to thirty seconds
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MB

Antonio Emanuele Vona

D027

BPPV is usually due to calcium carbonate particles (otoliths) that have become
dislodged from the otolith membrane and migrated to one of the semicircular
canals, where they typically float free in the endolymph though occasionally
they can adhere to the cupula
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The most common
form of BPPV is posterior canal BPPV, which is readily treatable with particle
repositioning maneuvers (typically the Epley maneuver) designed to move the
particles from the canal back into the central chamber of the inner ear, the
vestibule
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In horizontal canal BPPV, the nystagmus is in the horizontal plane and is
best triggered by having the patient lie supine and then roll over to either side
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In anterior
canal BPPV, the Hallpike maneuver triggers a burst of downbeat, torsional
nystagmus
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Epley Manoeuvre
Epley manoeuvre for treating posterior semicircular canal BPPV
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1 shows a patient whose
problem is in the right ear)
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Keep the
head in this position for at least a minute, then (3) roll the patient’s body in the
direction the head is already turned, maintaining the rotated position of the
head relative to the body so that the patient’s face is now pointed toward the
floor
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(Gelb, 2011)

Dr
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Symptoms are usually severe for hours to days, with residual
symptoms gradually resolving over days to months
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When a clear bacterial cause can be found, appropriate
antibiotics should be given
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Although the vertigo may improve over a week, sudden
head movements may provoke the vertigo for weeks
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It is believed that either a viral or bacterial infection
can cause damage to the inner ear
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Common bacterial causes
include Streptococcus pneumoniae
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MB

Antonio Emanuele Vona

D027

meningitides
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Viral infection is less fulminant and
may be reversible
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Otoscopic evaluation may reveal otitis media
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With
viral causes, a tapered course of oral prednisone may be helpful, but results
are varied
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References:
Blatt PJ, Georgakakis GA, Herdman SJ, Clendaniel RA, Tusa RJ
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Am J Otol 2000;21:356-363
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, 2011
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4th edition
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, Kim, J
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, benign paroxysmal positional vertigo
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2010;6:51-63
Souza, T
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Differential Diagnosis and management for the Chiropractor,
Protocols and algorithm
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Jones and Barlett publishers

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