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Benignparoxysmalpositionalvertigo

JNeurosciRuralPract.2011JanJun2(1):109110.

PMCID:PMC3122990

doi:10.4103/09763147.80091

Benignparoxysmalpositionalvertigo
GuoXiangDong
DepartmentofOtolaryngology,theFirstAffiliatedHospitalofHenanTraditionalChineseMedicalCollege,Zhengzhou,China
Addressforcorrespondence:Dr.GuoXiangDong,No.19RenminRoad,ZhengzhouChina450000Email:guoxiangdong0618@126.com
CopyrightJournalofNeurosciencesinRuralPractice
ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionNoncommercialShareAlike3.0Unported,whichpermitsunrestricteduse,distribution,and
reproductioninanymedium,providedtheoriginalworkisproperlycited.

Abstract

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Benignparoxysmalpositionalvertigo(BPPV)isacommonclinicaldisordercharacterizedbybriefrecurrentspellsofvertigooftenbroughtabout
bycertainheadpositionchangesasmayoccurwithlookingup,turningoverinbed,orstraighteningupafterbendingover.Itisimportantto
understandBPPVnotonlybecauseitmayavertexpensiveandoftenunnecessarytesting,butalsobecausetreatmentisrapid,easy,andeffectivein
>90%ofcases.ThediagnosisofBPPVcanbemadebasedonthehistoryandexamination.Patientsusuallyreportepisodesofspinningevokedby
certainmovements,suchaslyingbackorgettingoutofbed,turninginbed,lookingup,orstraighteningafterbendingover.Atpresent,the
generallyacceptedrecurrencerateofBPPVaftersuccessfultreatmentis40%50%at5yearsofaveragefollowup.Theredoesappeartobea
subsetofindividualspronetomultiplerecurrences.
Keywords:Benignparoxysmalpositionalvertigo,Benignparoxysmalpositionalvertigo,vertigo
Introduction

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Benignparoxysmalpositionalvertigo(BPPV)isacommondiseaseintheENT.ItisimportanttounderstandBPPVnotonlybecauseitmayavert
expensiveandoftenunnecessarytesting,butalsobecausetreatmentisrapid,easy,andeffectivein>90%ofcases.
BPPVisacommonclinicaldisordercharacterizedbybriefrecurrentspellsofvertigooftenbroughtaboutbycertainheadpositionchangesasmay
occurwithlookingup,turningoverinbed,orstraighteningupafterbendingover.BPPVisanimportantcauseofvertigowithaprevalenceof11
64per100,000andalifetimeprevalenceingeneralpracticeof2.4%.[1]
AnatomicBackgroundandMechanisticBasis

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Thevestibularpartofthemembranouslabyrinthconsistsof3semicircularcanals:theanterior,posterior,andthehorizontalcanals.Thesecanals
detectturningmovementsofthehead.Thelabyrinthalsoconsistsof2otolithstructures,theutricleandsaccule,thatdetectlinearacceleration,
includingdetectionofgravity.ThemaculaoftheutricleisthepresumedsourceofthecalciumparticlesthatcauseBPPV.Itconsistsofcalcium
carbonatecrystals(otoconia)embeddedinagelatinousmatrix,intowhichthestereociliaofhaircellsproject.BPPViscausedwhenotoliths
originatefromtheutricularmaculaandmovewithinthelumenofoneofthesemicircularcanals.Whenthecalciumcarbonatecrystalsmovewithin
thesemicircularcanal,theycauseendolymphmovementthatstimulatestheampullaoftheaffectedcanal,therebycausingvertigo.Thedirectionof
thenystagmusisdeterminedbyampullarynerveexcitationintheaffectedcanalbydirectconnectionstotheextraocularmuscles.Eachcanal
affectedbycanalithiasishasitsowncharacteristicnystagmus.
Thereasonforthissheddingofcalciumcrystalsfromthemaculaisnotwellunderstood.Thecalciumdebrismaybreakofffollowingtraumaor
viralinfections,butinmanyinstancesitseemstooccurwithoutidentifiableillnessortrauma.Itmayhavetodowithagerelatedchangesinthe
proteinandgelatinousmatrixoftheotolithicmembrane.[2]
BPPVmayaffecttheposterior,horizontal,oranteriorsemicircularcanal,andinsomecasesitmayeveninvolvemorethanonecanalatatime.
Duetoitsgravitydependentposition,themostcommonlyaffectedsemicircularcanalistheposteriorcanal.Theanteriorcanalandpolycanalicular
formsaretheleastcommon.[3]
Diagnosis

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ThediagnosisofBPPVcanbemadebasedonthehistoryandexamination.Patientsusuallyreportepisodesofspinningevokedbycertain
movements,suchaslyingbackorgettingoutofbed,turninginbed,lookingup,orstraighteningafterbendingover.Theepisodesofvertigolast
1030sandarenotaccompaniedbyanyadditionalsymptomsotherthannauseainsomepatients.
ThediagnosisofBPPVoftheposteriorcanalisconfirmedbyobservingparoxysmalpositionalnystagmuswiththeDixHallpikemaneuver.The
DixHallpikemaneuverisperformedbyrapidlymovingtheheadfromanuprighttoheadhangingpositionwithoneear45degreestotheside.
TheDixHallpikemaneuverresultsintorsionalupbeatingnystagmuscorrespondingindurationtothepatient'ssubjectivevertigo,andoccurring
onlyafterDixHallpikepositioningontheaffectedside.[4]
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Benignparoxysmalpositionalvertigo

ThemostreliablewaytodiagnosehorizontalBPPVisbyasupineheadturnmaneuver.Thepatient'sheadisturnedtooneside,thenisturnedback
tothesupinefaceupposition.Thentheheadisturnedtotheotherside.ThenystagmusofhorizontalcanalBPPV,unlikethatofposteriorcanal
BPPV,isdistinctlyhorizontalandchangesdirectionwithchangesintheheadposition.Theparoxysmaldirectionchangingnystagmusmaybe
eithergeotropicorapogeotropic.[5]
TheanteriorcanalformofBPPVisassociatedwithparoxysmaldownbeatingnystagmus,sometimeswithaminortorsionalcomponentfollowing
DixHallpikepositioning.[6]PolycanalicularBPPVisuncommon,butindicatesthat2ormorecanalsaresimultaneouslyaffectedatthesametime.
ThemostcommoncircumstanceisposteriorcanalBPPVcombinedwithhorizontalcanalBPPV.
Treatment

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ThetreatmentofposteriorcanalandanteriorcanalBPPVisthecanalithrepositioningmaneuver,sometimesreferredtoastheEpleymaneuver.
ThemostcommonlyusedtreatmentforhorizontalcanalBPPVistherollmaneuver.
Evidenceislackingtorecommendpostmaneuverrestrictionsinpatientstreatedwithcanalithrepositioningtherapies,althoughthereisgenerallyno
associatedharmwiththeseinstructions.[7]
Occasionally,freelymobileotoconiamovingwithinthelumenofonesemicircularcanalcanbemovedduringthecourseoftreatmentnotbackto
thevestibuleasintended,buttooneoftheadjacentcanals,asthecanalsalldirectlycommunicatewithoneanother.Themostcommoncanal
switchisfromtheposteriortothehorizontalandposteriortotheanteriorcanals.[8]
Complications

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Themostcommoncomplicationsincludenausea,vomiting,fainting,andconversiontolateralcanalBPPVduringthecourseoftreatmentdueto
canalswitch.[9]
Prognosis

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Atpresent,thegenerallyacceptedrecurrencerateofBPPVaftersuccessfultreatmentis40%50%at5yearsofaveragefollowup.Theredoes
appeartobeasubsetofindividualspronetomultiplerecurrences.[10]
Footnotes

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SourceofSupport:Nil
ConflictofInterest:Nonedeclared.

References

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1.vonBrevernM,RadtkeA,LeziusF,FeldmannM,ZieseT,LempertT,etal.Epidemiologyofbenignparoxysmalpositionalvertigo:A
populationbasedstudy.JNeurolNeurosurgPsychiatry.200778:7105.[PMCfreearticle][PubMed]
2.FifeD,FitzGeraldJE.Dopatientswithbenignparoxysmalpositionalvertigoreceiveprompttreatment?Analysisofwaitingtimesandhuman
andfinancialcostsassociatedwithcurrentpractice.IntJAudiol.200544:507.[PubMed]
3.BhattacharyyaN,BaughRF,OrvidasL,BarrsD,BronstonLJ,CassS,etal.Clinicalpracticeguideline:Benignparoxysmalpositionalvertigo.
OtolaryngolHeadNeckSurg.2008139:S4781.[PubMed]
4.JeongSH,ChoiSH,KimJY,KooJW,KimHJ,KimJS.Osteopeniaandosteoporosisinidiopathicbenignpositionalvertigo.Neurology.
200972:106976.[PubMed]
5.ProkopakisEP,ChimonaT,TsagournisakisM,ChristodoulouP,HirschBE,LachanasVA,etal.Benignparoxysmalpositionalvertigo:10
yearexperienceintreating592patientswithcanalithrepositioningprocedure.Laryngoscope.2005115:166771.[PubMed]
6.BalohRW,YueQ,JacobsonKM,HonrubiaV.Persistentdirectionchangingpositionalnystagmus:Anothervariantofbenignpositional
nystagmus?Neurology.199545:1297301.[PubMed]
7.LopezEscamezJA,MolinaMI,GamizM,FernandezPerezAJ,GomezM,PalmaMJ,etal.Multiplepositionalnystagmussuggestsmultiple
canalinvolvementinbenignparoxysmalvertigo.ActaOtolaryngol.2005125:95461.[PubMed]
8.RadtkeA,vonBrevernM,TielWilckK,MainzPerchallaA,NeuhauserH,LempertT.Selftreatmentofbenignparoxysmalpositionalvertigo:
SemontmaneuvervsEpleyprocedure.Neurology.200463:1502.[PubMed]
9.YimtaeK,SrirompotongS,SrirompotongS,SaeSeawP.Arandomizedtrialofthecanalithrepositioningprocedure.Laryngoscope.
2003113:82832.[PubMed]
10.HainTC,HelminskiJO,ReisIL,UddinMK.Vibrationdoesnotimproveresultsofthecanalithrepositioningprocedure.ArchOtolaryngol
HeadNeckSurg.2000126:61722.[PubMed]
ArticlesfromJournalofNeurosciencesinRuralPracticeareprovidedherecourtesyofMedknowPublications

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Benignparoxysmalpositionalvertigo

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