BPPV

Benign Paroxysmal Positional Vertigo

By
Wendy Carender, PT, NCS
Advanced Vestibular Certified Physical Therapist

Team of Audiologists at UMHS

Audiologists in Vestibular Testing Center

Assist in the Identification of BPPV:
Dix-Hallpike and Positional Testing during VNG

Assist in the Management of BPPV

Perform particle repositioning maneuvers for simple cases

Patients are referred to Vestibular PT and/or

Otolaryngologist for additional treatment and
diagnosis.

BPPV ( Positional Vertigo)

Benign: not life threatening, however symptoms

may be intense

Paroxysmal : occurs suddenly

Positional: provoked by change in position of

the head

Vertigo: sense of rotation or spinning usually

lasting less than one minute

BPPV

Most common peripheral vestibular disorder

2.4% of all people will experience BPPV at some
point in their lifetime ( Fife TD, Inversion DJ, Lempert T.
Neurology 2008)

Causes approximately 50 % of dizziness in older

adults ( Froehling DA, Silverstein MD, Mohr DN. Mayo Clinic Proc
1991)
Increased risk of falling

Enormous Health Care Burden

Estimated $2 billion per year

Easy to diagnosis and treat at the bedside

BPPV Causes

Primary cause in people over age 50 is idiopathic

Primary cause in people under age 50 is head

injury

Increase frequency of BPPV found in patients with

Migraine, Vestibular Neuritis and Menieres
Disease

BPPV occasionally occurs following other ear

surgery (stapedectomy) (AtacanE, Sennaroglu L,
Dene A. Laryngoscope 2001)

BPPV may develop after long periods of inactivity

BPPV History
History most important part of Vestibular Exam
First episode typically provoked by rolling over in
bed or getting out of bed
4 questions on Dizziness Handicap Inventory that
are helpful to screen for BPPV
- Looking up cause dizziness
- Getting in/out of bed
- Rolling over in bed
- Bending over

BPPV Anatomy

Vestibular organ: 3 semi-circular canals, utricle and

saccule.

Semi-circular canals: detect rotational movements and are

filled with endolymph
Ampulla: One end of each semicircular canal is widened to
form an Ampulla
Cupula: sensory receptor located within the Ampulla

2 otolith organs measure linear acceleration and detect head

tilt
Utricle (horizontally aligned) contains otoconia
Saccule (vertically aligned)

Anatomy of the Inner Ear

Source of figures: Furman JM, Cass SP. Vestibular Disorders: A Case Study Approach, 2nd ed., 2003.

Picture of Otolithic Macula

Otoconia

Otoconia: calcium carbonate crystals that are

attached to the otolithic membrane in the utricle

BPPV occurs when otoconia detach from the

utricular membrane and migrate into the semicircular canals.

Head movement
endolymph flow
signal to brain

otoconia shift
cupular deflection
false
vertigo and nystagmus.

Direction of Endolymph Flow is Important

Ampullopetal flow = flow towards ampulla (to seek)

In the horizontal SCC, this is excitatory. In the vertical canals, this is inhibitory.

Ampullofugal flow = flow away from ampulla (to flee)

In the horizontal canal, this is inhibitory. In the vertical canals, it is excitatory.

Ewalds Observations on
Semi Circular Canal Function

Eye movements occur in the plane of the SCC

being stimulated AND in the direction of the
endolymph flow

In the vertical canals, ampullofugal endolymph

flow canals causes a greater response (eye
movements) than ampulopetal flow

In the horizontal canals, ampullopetal

endolymph flow causes a greater response than
ampullofugal flow

Connections of SCCs with Extraocular Muscles

Figure source: Baloh RW, Honrubia V. Clinical neurophysiology of the vestibular system, 2nd edition. Philadelphia, PA: F.A. Davis Company; 1990.

Patterns of nystagmus associated with excitation

of individual semicircular canals
slow-phase
Left posterior

fast-phase

up-counterclockwise

Left superior
down-counterclockwise

Left lateral
Medical Illustration Copyright 2009 Nucleus Medical Art. All rights reserved. www.nucleusinc.com

left-beating

2 Types of BPPV

Canalithiasis
Most common form of BPPV
Otoconia float freely in endolymph
Latency (2-30 sec) in onset of vertigo and
nystagmus after the patient moves into the
provoking position
Fluctuation in intensity of vertigo and nystagmus,
with a typical crescendo-decrescendo pattern, which
resolves within 60 seconds.

2 Types of BPPV

Cupulolithiasis
Not as common
Otoconia adhere to the cupula
Immediate onset of vertigo and nystagmus when the
patient moves into the provoking position
Persistence of vertigo and nystagmus as long as the
patient remains in the provoking position (> 60 sec)

Important to differentiate between canalithiasis

and cupulolithiasis to help guide your choice of
treatment

Canal Involvement

Prevalence of BPPV (Fife and Lempert 2008)

Posterior canal: 81-89%
Horizontal/Lateral canal: 8-17%
Superior/Anterior canal: 1-3% of cases

Video goggles used to record eye movement: (Imai et

al 2005, Lopez-Escamez, et al 2005)

Posterior Canal: 41-65%

Horizontal canal: 21-33%
Superior canal: 17%
Multi-canal: 20% Common following head trauma.

Use Goggles for accurate diagnosis!

Dix-Hallpike Test (Barany Maneuver)

1952- Margaret Dix, MD and Charles S. Hallpike, MD

Gold standard test for diagnosis of posterior semi-circular

canal BPPV

Contraindications: severe RA, recent neck trauma or neck

surgery, vertebral basilar insufficiency, Chiari
Malformation

Infrared Goggles to record eye movements or room light

To perform the Dix-Hallpike test, begin with patient long

sitting on the treatment table with head rotated 45 right or
left, then quickly go to supine with head hanging slightly off
the table (20 extension).

Repetition of Dix-Hallpike results in fatigue of nystagmus

Picture Dix-Hallpike Test

Picture of Sidelying Test

To test the right ear,

turn patient head 45
to the left side and
have them quickly lay
down on their right
shoulder.

Wait at least 30
seconds for any
nystagmus to appear.

Pattern of Nystagmus for Positive Dix-Hallpike

Vertical Component
Upbeating: posterior canal
Downbeating: anterior canal or possibly central

Torsional Component (named from patient perspective)

Right Hallpike: right torsion, clockwise, beating towards the dependent
right ear
Left Hallpike: left torsion, counter clockwise, beating towards the
dependent left ear

Horizontal Component: horizontal canal, perform Roll Test

Duration
Less than 60 seconds: Canalithiasis
Greater than 60 seconds: Cupulolithiasis

Return to sitting: pattern of nystagmus reverses

BPPV

Treatment options:
Particle Repositioning Maneuvers (PRM): 75-80% success
rate in treating posterior canal BPPV in one office visit.
Modified Epley (Canalithiasis)
Liberatory/Semont (Cupulolithiasis)
Brandt-Daroff Habituation Exercises.
Watch and wait: otoconia dissolve over time.
Caution patient to avoid provoking positions due to increased fall risk

Surgery: posterior canal plugging.

Medication: Vestibular Suppressants (Meclizine, Valium) are
typically not helpful since this is a mechanical problem.

Treatment options-Maneuvers
Semicircular Canal
Involvement
Posterior- upbeating
torsional nystagmus

Canalithiasis

Cupulolithiasis

nystagmus< 60 seconds

nystagmus> 60 seconds

-Modified Epley (Particle

Repositioning Maneuver)

-Liberatory Maneuver
(mastoid vibration)

-Liberatory Maneuver

-Brandt-Daroff Exercises

Anterior- downbeating
torsional nystagmus

-Liberatory Maneuver
modified for AC
-Reverse Epley

-Liberatory Maneuver AC
(mastoid vibration)
-Brandt-Daroff Exercises

Horizontal- horizontal
geotropic or ageotropic
nystagmus

-Lempert 360 BBQ Roll

- Casini (Modified Semont)

-Appiani (modified Liberatory) -Brandt-Daroff modified for

Horizontal Canal
-Forced Prolonged Positioning

Modified Epley Maneuver (Left Ear)

Wait dizziness PLUS 30 seconds in each position.

Eye movements should remain ipsi-torsional throughout the maneuver.

180 rotation of the head is required to effectively clear the debris

(position B to D)

Guidelines for a Successful PRM

Each position must be held a minimum of 30 seconds to

allow the particle to settle ( Hain et al, 2004).

Perform at least 2 maneuvers within the treatment session

to optimize outcome. Wait at least 2 minutes in-between
maneuvers.

Only treat one ear, one canal at a time (24 hour period)

Activity Restriction: patients without activity restrictions

required more treatment sessions (Cakir, et al 2006)
Sit for 15 minutes with head level in the clinic

Avoid bending over or laying flat the rest of the day (can
sleep in regular position at night)

Liberatory/Semont Maneuver for Treatment of

Posterior Canal BPPV (Cupulolithiasis Variant)

Treatment shown for right

posterior canal

Turn head 45 away from the

affected side (left)

Quickly lay on affected side (right)

and wait 1 minute

Quickly move the patient to

opposite sidelying (< 1.5 seconds)
without changing the head position
and wait for 1 minute

Slowly return to sitting with the

head level

Figure source: Parnes LS, Agrawal S, Atlas J. Diagnosis and management of BPPV. CMAJ 2003;169(7):681-693.

Additional Recommendations for

Treatment of BPPV

Patient with bilateral posterior canal BPPV: treatment of

choice is Liberatory Maneuver to avoid triggering excessive
nausea. Treat one ear per session.

Treatment for severe nausea: Zofran or Compazine prior to

maneuvers.

Use tilt table if patient has limited cervical extension.

Cupulolithiasis not responding to maneuvers: add mastoid

vibration for 20 seconds in each position during maneuver.

Canal Conversion during PRM: 6% risk of conversion from

posterior to horizontal canal during the particle
repositioning maneuver.

Brandt-Daroff Habituation Exercises

Not as effective as repositioning maneuvers (Cohen HS,

Kimball KT. OtolNeurotol 2005;26: 1034-1040))

Mechanism
dislodges otoconia debris from the cupula
otoconia dissolve in endolymph
central adaptation occurs so patient less symptomatic

5 Repetitions, 2x/day for 2 weeks

Figure source: Google Images

Supine Roll test for Horizontal Canal BPPV

Supine Roll Test: tested in tranverse plane along the

longitudinal axis of the body with head elevated 20-30

0 neck flexion

Figure source: Heidenreich KD, Carender WJ, Heidenreich MJ, Telian SA. Annals of Vascular Surgery 2010; 24(4):553.e5.

Roll Test for Horizontal Canal BPPV

Roll Test is used for horizontal canal BPPV.

Patient is supine with the head flexed 20. Head is
quickly turned to one side for 60 seconds and
nystagmus is observed. Return to head center
position and wait a few seconds. Then the head is
quickly turned to the other side for 60 seconds. If
the patient does not have full cervical rotation, then
have the patient quickly roll onto their right or left
sides.
Similar to Head and Body Right/Left Positional
Testing

Horizontal/Lateral Canal BPPV

Lateralization of Side of Involvement

Positive Roll Tests = horizontal nystagmus and vertigo

would occur when the head is turned to both sides due to the
co-planar orientation of the canals

Geotropic (towards the earth) Nystagmus:

debris located in the long arm of the horizontal canal
side of greatest intensity is the affected lateral canal

Ageotropic (away from the earth) Nystagmus:

debris attached to the cupula OR otoconia lie close
to the ampulated end of the canal.
side of lesser intensity is the affected lateral canal

Left Geotropic Horizontal Canal BPPV

Geotropic HSC BPPV is due to canalithiasis where the otoconial
debris lies far away from the ampullated end of the canal.

In left ear down position, there is ampullopetal migration of otoconia. This is excitatory in the left HSC
and pt develops a Left Beating nystagmus.

In right ear down position, there is ampullofugal migration of otoconia. This is inhibitory,
and the pt develops a Right Beating nystagmus.
Figure courtesy of J.A White, MD, PhD

Treatment of Geotropic Horizontal Canal

BPPV Right Ear-Lempert BBQ Roll

270 -vs- 360 log roll- 30 seconds in each position

Use caution to avoid over rotation with the 360 maneuver!

Modified Libertory maneuver (Appiani) for

Horizontal Canalithiasis (Geotropic)
Patient begins with head in a
neutral position and quickly
lies down on the unaffected
side and waits for one minute.
Patient turns head 45 degrees
downward and waits for one
minute.

Photo from Herdman 2007

Patient slowly returns to sitting

with their head level.
Treatment show is for the
LEFT ear

Conversion of Ageotropic Nystagmus to

Geotropic Nystagmus in Horizontal Canal

Head Shaking (Vanmicci et al 1992)

20 head oscillations in the horizontal plane with the
patient supine and head tilted 30 forward

Rapid Rolling (Lempert 1994)

Rapidly roll from side to side 10 times.

Head Pitching ( Califano, et al 2008)

Pitch head 60 forward and 45 backward 20 times.

Modified Semont (Casini) for Horizontal

Canal Cupulolithiasis (Ageotropic )

Patient moves quickly from

sitting with head in neutral
to sidelying on the affected
side.

Head is immediately turned

so the nose is down 45.

Patient stays in this position for

2 minutes, then slowly returns
to sitting.

Treatment shown for the right

ear

Photo from Herdman 2007

Factors Contributing to Recurrence

Rate of recurrence is 15% per year, cumulative.

Rate of recurrence may be as high as 25% in

the first year, 44% in second year (Hain,
Helminski, 2000)

Factors contributing to recurrence:

Head Trauma

A daily routine of Brandt-Daroff Exercise or

Epley maneuver does not affect the time to
recurrence or the rate of recurrence.
Helminski JO, JanssenI, Hain TC. Otol & Nerotol 2008;29:976-981.

Clinical Practice Guidelines: BPPV

Otolaryngology-Head and Neck Surgery 2008

Recommended against full vestibular testing or
radiographic imaging in routine cases.
Dix-Hallpike and Positional Testing with Videogoggles
would be indicated if BPPV is suspected.

Recommend against treatment with vestibular

suppressants like benzodiazepines or antihistamines.
Recommend clinicians reassess BPPV patients
within one month of treatment to confirm resolution.

Modified Liberatory Maneuver

Horizontal Canal BPPV

Positive Roll Tests = horizontal, bidirectional

nystagmus

Geotropic (towards the earth) Nystagmus:

side of greatest intensity is the affected lateral canal

Ageotropic (away from the earth) Nystagmus:

side of lesser intensity is the affected lateral canal

Vestibular PT Evaluation (later same day)

Roll Tests in room light

Right Roll: left beating horizontal nystagmus lasting
> 60 seconds
Left Roll: right beating horizontal nystagmus lasting
> 60 seconds.
Nystagmus appeared to be of equal intensity to both
sides. Speed of the roll/head movement will affect
the response!
Patient was more symptomatic when rolling to the
RIGHT side.