Benign paroxysmal positional vertigo

Question 1

BPPV

Answer 1

a common type of vertigo

induced by changing head position

—particularly tilting the head backwards,

• changing from a recumbent to a sitting position or
• turning to the affected side.

Question 2

Clinical features

Answer 2

Affects all ages, esp. elderly.

The female to male ratio is 2:1

Recurs periodically for several days

Each attack is brief,

• usually lasts 10–60 seconds
• subsides rapidly

Severe vertigo on getting out of bed

Can occur on head extension and turning head in bed

Attacks not accompanied by:

• vomiting
• tinnitus or
• deafness (nausea may occur)

Usually spontaneous recovery in wks (most return to regular activity after 1 wk)

Question 3

Causes

Answer 3

In one large series:

• 17% were associated with trauma,
• 15% with viral labyrinthitis
• 50% had no clear predisposing factor other than age.

One accepted theory of causation is that:

• fine pieces of floating crystalline calcium carbonate deposits (otoconia)
• that are loose in the labyrinth settle in the posterior semicircular canal
• and generate endolymphatic movement.

It may also be a variation of cervical dysfunction.

Question 4

Diagnosis

Answer 4

Confirmed by head position testing.

From a sitting position the pt’s head is rapidly taken to a head-hanging position 30 ° below the level of the couch

— do three times, with the head

(1) straight
(2) rotated to the right
(3) rotated to the left.

Hold on for 30 seconds and observe the patient carefully for vertigo and nystagmus.

There is a latent period of few seconds before the onset of the symptoms

Tests of hearing and vestibular function are normal

Question 5

Management

Answer 5

can be managed in primary care

• successful in about 80% of pts

Give appropriate explanation and reassurance

Encourage the patient to move in a certain ways that avoid the attack

Drugs are not recommended

Special exercises (e.g. Cawthorne–Cooksie exercises)

Particle repositioning manoeuvres , e.g. Epley, Semont, by doctor

Cervical traction may help

Surgical Rx rarely required; it involves

• occlusion of the posterior semicircular canal
• rather than selective neurectomy

Question 6

Particle repositioning manoeuvres

Answer 6

1) Patient-performed exercises.

Most pts appear to benefit from exercise, such as:

• the Brandt and Daroff procedure 12 or
• the Cawthorne–Cooksey exercises
• that consist essentially of repeatedly inducing the symptoms of vertigo.

Rather than resorting to avoidance measures,

Pt is instructed to:

• perform positional exercises to induce vertigo,
• hold this position until it subsides,
• and repeat this many times until the manoeuvre does not precipitate vertigo.

The attacks then usually subside in a few days.

2) Therapist-performed exercises.

• Physical manoeuvres performed as an office procedure
• include the Epley and Semont manoeuvres (refer ).

Question 7

What are Brandt-Daroff exercises?

Answer 7

1. Start sitting upright on the edge of the bed.
2. Turn your head 45 degrees to the left, or as far as is comfortable.
3. Lie down on your right side.
4. Remain in this position for 30 seconds or until any dizziness has subsided.
5. Sit up and turn head back to centre.
6. Turn your head 45 degrees to the right, or as far as is comfortable.
7. Lie down on your left side.
8. Remain in this position for 30 seconds or until any dizziness has subsided.
9. Sit up and turn head back to centre.

The above description is one repetition.

The exercises should be performed in a set of 5 repetitions.

They should be performed three times a day for two weeks

Question 8

What is the benefit of doing the Brandt-Daroff exercises?

Answer 8

The exercises can stop the dizzy spells experienced by BPPV sufferers.

It is not clear why the exercises work;

Some evidence suggests that the exercises help to relocate the loose crystals that cause the dizziness in the first place

Whereas other evidence suggests that repeated exposure to the feeling of dizziness reduces its intensity

Question 9

What are the risks or disadvantages of Brandt-Daroff exercises?

Answer 9

likely to provoke dizziness

• so should be performed in a safe environment,
• preferably with another person present.

Some people find it difficult to persevere with the exercises, but they have a good success rate.

Question 10

Outcome

Answer 10

There is usually spontaneous recovery in weeks

• most return to regular activity after 1 week

Recurrences are common: attacks occur in clusters