Ear, Nose & Throat
Question 128 of 180
A 34 year old woman presents to the Emergency Department complaining of "dizziness whenever I move". She describes episodes of vertigo lasting 1-2 minutes whenever she changes her position. On occasion these episodes are so severe she vomits. What is the most likely diagnosis?
Answer:
Benign paroxysmal positional vertigo (BPPV) is defined as a disorder of the inner ear characterised by repeated episodes of positional vertigo. It is thought to be caused by loose calcium carbonate debris (otoconia) in the semicircular canals of the inner ear (canalithiasis).- Symptoms are brought on by specific movements and positions of the head relative to gravity (for example lying down, turning over in bed, looking upwards, or bending over). People may modify their movements to limit symptoms.
- Vertigo occurs in transient episodes (typically lasting less than 1 minute), which are preceded by position change, with the person being asymptomatic between attacks. It is common for the person to overestimate the duration of an episode.
- Nausea and vomiting may occur.
Benign Paroxysmal Positional Vertigo
Ear, Nose & Throat
Last Updated: 12th February 2021
Pathophysiology
Benign paroxysmal positional vertigo (BPPV) is defined as a disorder of the inner ear characterised by repeated episodes of positional vertigo. It is thought to be caused by loose calcium carbonate debris (otoconia) in the semicircular canals of the inner ear (canalithiasis). When the head moves, otoconia move in the semicircular canals, causing motion of the fluid of the inner ear (endolymph) which induces the symptom of vertigo. The posterior semicircular canal is the most commonly affected (in around 85–95% of people with BPPV).
BPPV can be precipitated by a head injury, a prolonged recumbent position (for example during a visit to the dentist or hairdresser), ear surgery, or following an episode of any inner ear pathology (for example, vestibular neuronitis, labyrinthitis, Meniere's disease). BPPV is the most common cause of vertigo encountered in clinical practice. BPPV can affect people of any age, but commonly presents between the fifth and seventh decades. Women are affected more often than men.
Diagnosis
- Ask about symptoms of vertigo:
- Symptoms are brought on by specific movements and positions of the head relative to gravity (for example lying down, turning over in bed, looking upwards, or bending over). People may modify their movements to limit symptoms.
- Vertigo occurs in transient episodes (typically lasting less than 1 minute), which are preceded by position change, with the person being asymptomatic between attacks. It is common for the person to overestimate the duration of an episode.
- Nausea and vomiting may occur.
- Lightheadedness and imbalance are sometimes reported and can persist for longer than the vertigo episode.
- Hearing is not affected (although hearing impairment may coexist for a different reason).
- Tinnitus is not a feature of benign paroxysmal positional vertigo.
- Examine the person to elicit signs suggestive of a diagnosis of benign paroxysmal positional vertigo and exclude other conditions:
- Examination is likely to be normal at rest in a sitting position.
- Perform a full ear, nose, and throat, cardiovascular, and neurological examination to exclude other causes of vertigo.
- Diagnose posterior semicircular canal BPPV if the Dix-Hallpike manoeuvre provokes vertigo and torsional (rotatory) upbeating nystagmus (the upper pole of the eye beats towards the dependent ear with the vertical component towards the forehead when looking straight ahead). Left ear BPPV has a clockwise torsional nystagmus, right ear BPPV nystagmus rotates anti-clockwise.
- There is a latent period (usually of 5 to 20 seconds) between completing the manoeuvre and onset of vertigo and nystagmus.
- The vertigo and nystagmus increase in intensity, then decline, but should resolve within 1 minute of nystagmus onset.
- Less intense nystagmus in the opposite direction may occur for a short time on sitting upright.
- Investigations are not usually required, diagnosis is clinical.
Dix-Hallpike manoeuvre
- Be cautious if considering the Dix-Hallpike manoeuvre if the person has a neck or back problem, or cardiovascular problems such as carotid sinus syncope, as it involves turning the head and extending the neck.
- Advise the person that they may experience transient vertigo during the procedure.
- Ask the person to keep their eyes open throughout the manoeuvre and to look straight ahead.
- Ask the person to sit upright on the couch with their head turned 45 degrees to one side.
- From this position, lie the person down rapidly (over 2 seconds), supporting their head and neck, until their head is extended 20–30 degrees over the end of the couch with the chin pointing slightly upwards and the test ear downwards. Support the head to maintain this position for at least 30 seconds.
- Observe their eyes closely for up to 30 seconds for the development of nystagmus. If nystagmus is present, maintain the position for its duration (maximum 2 minutes if persistent) and note its duration, type, direction, and latency.
- Support the head in position and slowly sit the person up.
- Repeat with the head rotated 45 degrees to the other side.
- On repeat testing, the nystagmus becomes less obvious (fatigues). However, it is not recommended to repeat the Dix-Hallpike manoeuvre to confirm fatiguability because of the unpleasant vertigo symptoms it induces.
Management
- Advise patients:
- Most people recover over several weeks, even without treatment, but symptoms can last much longer and may recur.
- A simple repositioning manoeuvre can help alleviate their symptoms in most cases.
- To get out of bed slowly and to avoid tasks that involve looking upwards.
- Not to drive when they are dizzy, or if they might experience an episode of vertigo while driving.
- Treatment:
- Discuss the option of watchful waiting to see whether symptoms settle without treatment. Explain that treatment may help the person's symptoms resolve more quickly.
- Offer a particle repositioning manoeuvre, such as the Epley manoeuvre. Ideally, this should be done at the first presentation if the expertise and time are available. Symptoms may improve shortly after treatment, but full recovery can take days to a couple of weeks. If symptoms do not settle after 1 week and the diagnosis of BPPV is not in doubt, advise the person to return and consider repeating the Epley manoeuvre.
- Consider suggesting Brandt-Daroff exercises which the person can do at home, particularly if the Epley manoeuvre cannot be performed immediately or is inappropriate.
- Symptomatic drug treatment is not usually helpful for people with BPPV.
- Advise the person to return for follow up in 4 weeks if symptoms have not resolved in case BPPV has been incorrectly diagnosed.
Epley manoeuvre
- Be cautious performing the Epley manoeuvre if the person has neck or back problems, unstable cardiac disease, suspected vertebrobasilar disease, carotid stenosis, or morbid obesity.
- Advise the person that they will experience transient vertigo during the manoeuvre.
- Stand at the side or behind the person to guide head movements. Maintain each head position for at least 30 seconds. If vertigo continues, wait until it has subsided.
- Ideally, movements should be rapid, within 1 second, but this is often not possible, particularly in older people. Expert opinion suggests that the procedure can be effective if movements are carried out slowly.
- Start with the person sitting upright with their head turned 45 degrees to the affected side, then lie them back (with their head still turned 45 degrees) until the head is dependent 30 degrees over the edge of the couch (as if performing the Dix-Hallpike manoeuvre). Wait for at least 30 seconds. Then:
- With the face upwards, but still tilted backwards by 30 degrees, rotate the head through 90 degrees to the opposite side.
- Hold the head in this position for about 20 seconds and ask the person to roll onto the same side as they are facing.
- Rotate the person's head so that they are facing obliquely downward with their nose 45 degrees below the horizontal.
- Sit the person up sideways while the head remains rotated and tilted to the side.
- Rotate the head to the central position and move the chin downwards by 45 degrees.
- There is usually no need to advise the person of any positional restrictions after the procedure has been performed.
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- Biochemistry
- Blood Gases
- Haematology
| Biochemistry | Normal Value |
|---|---|
| Sodium | 135 – 145 mmol/l |
| Potassium | 3.0 – 4.5 mmol/l |
| Urea | 2.5 – 7.5 mmol/l |
| Glucose | 3.5 – 5.0 mmol/l |
| Creatinine | 35 – 135 μmol/l |
| Alanine Aminotransferase (ALT) | 5 – 35 U/l |
| Gamma-glutamyl Transferase (GGT) | < 65 U/l |
| Alkaline Phosphatase (ALP) | 30 – 135 U/l |
| Aspartate Aminotransferase (AST) | < 40 U/l |
| Total Protein | 60 – 80 g/l |
| Albumin | 35 – 50 g/l |
| Globulin | 2.4 – 3.5 g/dl |
| Amylase | < 70 U/l |
| Total Bilirubin | 3 – 17 μmol/l |
| Calcium | 2.1 – 2.5 mmol/l |
| Chloride | 95 – 105 mmol/l |
| Phosphate | 0.8 – 1.4 mmol/l |
| Haematology | Normal Value |
|---|---|
| Haemoglobin | 11.5 – 16.6 g/dl |
| White Blood Cells | 4.0 – 11.0 x 109/l |
| Platelets | 150 – 450 x 109/l |
| MCV | 80 – 96 fl |
| MCHC | 32 – 36 g/dl |
| Neutrophils | 2.0 – 7.5 x 109/l |
| Lymphocytes | 1.5 – 4.0 x 109/l |
| Monocytes | 0.3 – 1.0 x 109/l |
| Eosinophils | 0.1 – 0.5 x 109/l |
| Basophils | < 0.2 x 109/l |
| Reticulocytes | < 2% |
| Haematocrit | 0.35 – 0.49 |
| Red Cell Distribution Width | 11 – 15% |
| Blood Gases | Normal Value |
|---|---|
| pH | 7.35 – 7.45 |
| pO2 | 11 – 14 kPa |
| pCO2 | 4.5 – 6.0 kPa |
| Base Excess | -2 – +2 mmol/l |
| Bicarbonate | 24 – 30 mmol/l |
| Lactate | < 2 mmol/l |
