what is the most common cause of recurrent and episodic vertigo from a peripheral disorder?
BPPV
what is the peak age range of primary BPPV?
50-70
what are the characteristics of BPPV?
brief episodes of vertigo that start suddenly
perception of spinning when head is moved
vertigo with rolling over in bed, looking up/down
may be accompanied with nausea and vomiting
balance problems/lightheadedness may last for hours or days following the episode
can by annoying, disruptive, and often results in changes with normal activities
no hearing loss or tinnitus
spontaneous remission is common
what is the mechanism for cupulolithiasis?
debris, probably fragments of otoconia from the utricle adhere to the cupula
what is the mechanism for canalithiasis?
debris floating freely in endolymph in the long arm of the SCC
what are the symptoms of cupulolithiasis?
immediate onset of vertigo when the patient is moved into the provoking position
presence of nystagmus
persistence of vertigo and nystagmus as long as the patient’s head is in the provoking position
what are the symptoms of canalithiasis?
delay in the onset of vertigo by 1-40 sec after being placed in the provoking position
presence of nystagmus
intensity of vertigo and nystagmus increases and then decreases, disappearing within 60 sec
what is the gold standard of diagnosing BPPV?
dix-hallpike
what are some precautions to BPPV maneuvers?
cervical or occipitoatlantal instability
prolapsed intervertebral disk with radiculopathy
cervical myelopathy
arnold chiari malformation
vascular dissection syndromes
previous cervical spine surgery
acute trauma to the neck
RA
carotis sinus syncope
aplasia of the odontoid process
what does nystagmus look like if BPPV is in the posterior canal?
upbeating and torsional towards the down ear
what does nystagmus look like if BPPV is geotropic in the horizontal canal?
fast beats to the earth
what does nystagmus look like if BPPV is in the anterior canal?
downbeating and torsional away from the down ear
what does nystagmus look like if BPPV is ageotropic in the horizontal canal?
fast beats away from the earth
what are the steps to dix-hallpike
rotate head to side being tested
extend head 20-30 deg of bed edge
watch eyes for nystagmus
POST/ANT CANAL
what are the original 5 key elements of the canalith repositioning procedure?
premedication
specific positions
timing of shifts
use of vibration
post-maneuver instructions
what are the 4 positions of the epley?
neck extended turned to treatment side
neck extended turned away from treatment side
rolled onto affected side, chin tucked into chest, nose down
sit up with chin tucked and slowly bring to neutral
what is a tumarkin’s otolithic crisis?
drop attacks
hair cells suddenly activated and cause disrupted balance
fall to ground without warning
postural extensor response
what are the steps to the sidelying test?
turn pt head away from test side
lies down on test side
after symptoms resolve, return to sitting
POST/ANT CANAL
what are the steps to the semont maneuver?
turn pt head away from test side
lies down on test side
make a rainbow and end on the other side with head tucked and nose down
sit up with chin tucked and slowly bring head to neutral
how long should you wait between positions in the manuevers?
1-2 minutes
what are the steps to the roll test?
pt lies supine with head elevated to 30deg
roll body to left
return to neutral
roll body to right
HORIZONTAL
both sides will have nystagmus, one will be stronger
what is geotropic nystagmus?
otoconia in posterior segment of canal
symptoms stronger when head it toward affected side
to the ground
what is ageotropic nystagmus?
otoconia adhered to cupula
symptoms weaker when head turned to affected side
away from the ground
what is the bow and lean test?
for those with limited mobility
pt bows head over 90 deg forward
pt leans backward over 45 deg
HORI CANAL
