BPPV: and its role in Geriatric functioning

By: Jere Hess SPTA

Vestibular System• To understand BPPV, understanding the anatomy and functioning of vestibular system is crucial.• Equilibrium

• Balance • Spatial orientation

• Innervated by Cranial Nerve VIII (Vestibulocochlear Nerve)• Sensory Nerve• 2 branches

• Vestibular and Cochlear• Cochlear Branch

• Axons from the organ of corti • Function is hearing

• Vestibular Branch • Axons from the semicircular canals, saccule, and utricle• Function is equilibrium

• Primary organs• Semicircular canals • Otolithic organs

Vestibular System (Semi-circular canals)• 3 semicircular canals “SCC” (One set in each inner ear)

• Anterior (a.k.a superior), posterior, and horizontal (a.k.a lateral)• Contains endolymphatic fluid• Detect angular rotation of the head

• Collectively the anterior and posterior canals are called the verticle semicircular canals• Detect flexion and extension of head in saggital plane• Nodding head to say “yes”

• Horizontal Canal • Detects rotation of head in transverse plane • Rotating head to say “no”

• Cupula• A cupula is located at the end of each SCC in the ampulla

Vestibular System (Otolithic Organs)• Detect Horizontal and Vertical displacement• Primary Otolithic Organs

• Saccule • Responds to vertical displacement as in jumping rope (not a recommended Tx for Pleasant Acres

Residents)• Utricle

• Responds to horizontal displacement• Contains Otoconia (calcium carbonate crystals ). Utricle is the only place in the vestibular system

that should contain otoconia.

What is BPPV?• Benign (non-life threatening)• Paroxysmal (Sudden onset, brief duration, non-constant)• Positional (Onset triggered by head/body position)• Vertigo (False sense of rotational movement)• Most common cause of vertigo

• Recall; vertigo is the sense of everything around you spinning.• Often confused with dizziness and lightheadedness.

Who is affected by BPPV• 107 per 100,000 per year (lifetime prevalence of 2.4%)• Women more prevalent than men 2:1• Rare in children• Can affect adults of any age

• Commonly onset is not until at least the age of 50

• Seniors particularly affected by BPPV• Which significantly increases risk of falls

• Primary reason a SNF should be concerned with Dx and Tx BPPV

BPPV cont• Etiology

• 40% idiopathic• Trauma, migraines, inner ear infection or disease, diabetes, osteoporosis, intubation, reduced

blood flow.• Tx options

• Canalith repositioning (most common and high success rate)• Habituation techniques• Medications

• meclizine (Antivert, Bonine, Dramamine II, D-Vert), diazepam (Valium), dimenhydrinate , Dramamine), promethazine (Phenergan), scopolamine (Isopto, Scopace)

• Medications do not cure BPPV, rather they act as a vestibular suppressant to reduce s/s.• Cost and adding more medications to an already highly medicated population?

• Surgery• Canal plugging surgery. (90% success rate)

Why does BPPV occur?• Otoconia (calcium carbonate crystals) that are only supposed to be

located in the maculae of the utricle break loose and migrate into the SCC or cupula.• Endolymphatic fluid located in the SCC does not respond to changes in

gravity but the otoconia does react to gravity.• When someone changes position (particularly head position) the

otoconia move with the change and gravity, and stimulate nerve endings (stereocillia: tallest of which is called kinocillium) which sends false information. The false information is not perceived by visual system, proprioceptive system, or even the other ear which causes the brain to perceive the information as spinning/vertigo.• Stereocillia move towards the kinocillium is depolarizing and stereocillia moving

away from the kinocillium is hyperpolarizing

Dx of BPPVPosterior Semi circular canalithiasis is most common Dx 85-95%Horizontal/lateral canalithiasis Dx 5/15%Anterior Semicircular canalithiasis Dx less than 1%

Dx of BPPV• Nystagmus identified with positional changes

• Nystagmus is a specific pattern of eye movement• In this case, caused by the dislodged otoconia providing false information

• Nystagmus is named for the fast-phase of eye-beating• Nystagmus in relation to BPPV should never change direction. Ex: If nystagmus is geotropic

to L should be geotropic to R.• If Nystagmus does change direction, suspect other factors (unilateral peripheral loss)

• Peripheral problem (inner ear) caused Nystagmus will be more severe without visual fixation (Reason for dark room for BPPV testing)

• Central problem (brain) caused Nystagmus will NOT be more severe without visual fixation• Two primary positional Dx tests

• Dix Hall-Pike test:• Supine Roll Test:

Dx cont. Dix-Hallpike• Used to Dx an Anterior or Posterior SCC/cupula• Have pt. wear Frenzel lenses and darken room to limit visual fixation.• Place pt. in long-sitting.• Rotate pt. head 45 degrees to L or R and place pt. head in 45 degrees of neck

extension.• Support pt. head and neck while they lie supine while maintaining head position.• Rotate head 90 degrees to opposite side of starting position while maintaining 45

degrees of neck extension.• Pt. should then be placed in side lying towards direction of head rotation. Then

rotate 45 degrees for pt. to be facing ground while side lying. Then assist pt. to return short-sitting while maintaining pt. safety and assuring they are steady in short sitting position.• For elderly can use alternate side lying test position.

Dx cont. Dix-Hallpike• Determined by pt. position, direction of nystagmus, and duration of nystagmus.• Pt position supine head rotated 45 degrees left and 30 degrees of extension lines

up Left posterior SCC and Right anterior SCC.• Up beating nystagmus with torsion <60 seconds indicates Left posterior canalithiasis• Up beating nystagmus with torsion >60 seconds indicates Left posterior cupulolithiasis• Down beating nystagmus with torsion <60 seconds indicates Right anterior canalithiasis• Down beating nystagmus with torsion >60 seconds indicated Right anterior cupulolithiasis

• Important note: Any nystagmus without torsion is indicative of a CNS problem and neurologist and M.D. should be contacted immediately.

Dx cont. Dix Hallpike• Pt position supine head rotated 45 degrees right and 45 degrees of extension

lines up Right posterior SCC and Left anterior SCC.• Up beating nystagmus with torsion <60 seconds indicates Right posterior canalithiasis• Up beating nystagmus with torsion >60 seconds indicates Right posterior cupulolithiasis• Down beating nystagmus with torsion <60 seconds indicates Left anterior canalithiasis• Down beating nystagmus with torsion >60 seconds indicated Left anterior cupulolithiasis

Tx of Anterior or Posterior SCC/cupula BPPV• Epley maneuver

• Same maneuvering as Dix Hall-Pike beginning in affected position• After nystagmus resolves in initial position and subjective c/o vertigo have stopped maintain position for 30-

60”. Then proceed to next position waiting 30-60” at each new position until maneuver is completed• For cupulithiasis add percussion/vibration to mastoid process on side head is rotated towards in initial Epley

maneuver position.• Cupulolithiasis is more difficult to Tx than Canalithiasis because cupula is more dense and is a further

distance from utricle.• Repeat maneuver up to 3x in one Tx session. (Research shows 3 Epley’s is most effective even if Nystagmus

is not present after first Epley maneuver)• Pt should be educated and pt. should keep head elevated above 45 degrees for 24 hours following

repositioning.

• Other Tx options• Brandt Exercises for habituation• Modified Epley• Semont (caution with elderly due to rapid acceleration)• If unresponsive for >6 months to repositioning consider canal plugging surgery

Dix Hallpike & Epley illustration

Dx Supine Roll Test• a.k.a Pagnini-McClure maneuver• Used if BPPV is suspected and Dix-Hallpike results are negative.• Used to Dx Horizontal SCC/cupula• Pt. positioned in supine• Rotate head 90 degrees to either side and examine for nystagmus.

• If there is nystagmus wait 60” after nystagmus subsides

• Rotate head 90 to start position for 60” • Rotate head 90 degrees to opposite side and examine for nystagmus

• If there is nystagmus wait 60” after nystagmus subsides

Dx: Supine Roll Test cont.• Nystagmus is named geotropic or ageotropic for supine roll test

• Geotropic=towards earth.• Ageotropic=away from earth. Less common

• Geotropic nystagmus: indicates otoconia is stuck in posterior arm of horizontal SCC• Geotropic nystagmus <60”=Horizontal canalithiasis with the affected side being the more severe• Geotropic nystagmus >60”=Not BPPV and indicates CNS problem

• Ageotropic nystagmus: indicates otoconia is stuck in anterior arm of horizontal SCC/cupula• Ageotropic nystagmus <60”=Horizontal canalithiasis with symptoms more intense to unaffected side• Ageotropic nystagmus >60”=Horizontal cupulolithiasis with symptoms more intense to unaffected side

Supine Roll Test Image

Tx: Geotropic Horizontal Canal BPPV• BBQ Roll (a.k.a Lempert Roll Maneuver)

• Begin in supine with pt. head rotated 90 degrees to affected side. Rotate head 45 degrees to opposite side. Rotate head another 45 degrees. Place pt. in side lying and then rotate head 45 degrees. Move pt. to prone on elbows with chin tucked. Continue with this progression for an entirety of 270 degrees of rotation of pt. body and 360 degrees of rotation of pt. head.

• After each movement wait 30” after nystagmus subsides.

• Gufani Maneuver for can also be utilized• Begin with pt. in short sitting. From short sitting position you quickly place pt. in side lying towards

unaffected side for 2’. Then rotate pt. head 45 degrees facing downward and maintain this position for 2’. Pt is then returned to short sitting while maintaining head orientation.

Tx: Ageotropic Horizontal canal/cupula

• Slightly different Gufani Maneuver for Ageotropic horizontal canalithiasis• Pt begins and short sitting and is quickly placed in side lying on the affected side. After 1’ the pt. head is rotated 45

degrees upward towards the ceiling. After 2’ pt. is returned to short sitting while maintaining pt. head orientation.

• Ageotropic horizontal cupulolithiasis is Tx with rapid side lying to the affected ear with head tilted forward 20 degrees. Re-test with supine roll test and if Ageotropic for <60” repeat the above Gufani maneuver.

• Important Dx note: If Dix-Hallpike and Supine Roll Test are negative and simply means there is no BPPV or Inactive BPPV.

• Recurrence rate of BPPV once repositioned is 40-50% at 5 years• Complications

• Most common are nausea, vomiting, fainting, and conversion to horizontal canal BPPV during the course of treatment due to "canal switch" that occurs 6% of the time during canalith repositioning Tx, which underscores the importance of recognizing the horizontal canal variant of BPPV.

• Contraindications and Precautions• Severe Orthostatic BP• Unstable cervical spine injury or pt. who can’t safely have their head moved should have treatment deferred

Post-canalith repositioning Tx• Often times after BPPV a pt. will experience a vestibular deficit and/or

unilateral peripheral loss.• If unilateral peripheral loss is stable, pt. is a great candidate for PT services.

• Unaffected portions of vestibular system can compensate for affected portions of vestibular system.

• How to Tx resulting vestibular deficit or peripheral loss?• Dynamic and Static balance Tx

• Utilizing Head turns, vertical and horizontal displacement, and challenging visual and proprioceptive systems which forces the vestibular system to increase function to maintain balance.

• VOR x1 and VORx2

Geriatrics and BPPV studies• Unrecognized benign paroxysmal positional vertigo in elderly patients.

• Balance disorders in elderly patients are associated with an increased risk of falls but are often difficult to diagnose because of comorbid chronic medical problems. We performed a cross-sectional study to determine the prevalence of unrecognized benign paroxysmal positional vertigo (BPPV) and associated lifestyle sequelae in a public, inner-city geriatric population. Dizziness was found in 61% of patients, whereas balance disorders were found in 77% of patients. Nine percent were found to have unrecognized BPPV. Multivariate analysis demonstrated that the presence of a spinning sensation and the absence of a lightheadedness sensation predicted the presence of unrecognized BPPV. Patients with unrecognized BPPV were more likely to have reduced activities of daily living scores, to have sustained a fall in the previous 3 months, and to have depression. These data indicate that unrecognized BPPV is common within the elderly population and has associated morbidity.

Geriatrics and BPPV studies cont.• “The characteristic differences of benign paroxysmal positional vertigo among the elderly and the younger patients: A 10-year

retrospective review.”• OBJECTIVE: To compare the clinical characteristics of benign paroxysmal positional vertigo (BPPV) between the elderly and the younger

patients.• MATERIAL AND METHOD: The medical records of BPPV patients with positive testing result on the Dix-Hallpike or supine roll test

between January 2002 and December 2012 at Songklanagarind hospital, Thailand were retrospectively reviewed.• RESULTS: Of the 951 BPPV patients, 595 patients were in the younger group (age < or =60-year-old, mean age = 46.9+/-8.9 years) and

356 patients were in the elderly group (age >60-year-old, mean age = 69.3+/-6. 7years). The most common etiology of BPPV was idiopathic. No significant difference was found regarding gender and semicircular canals that were involved in both groups. The most involved semicircular canal was the posterior canal. The most common described symptom of BPPV was vertigo. Patients in the elderly group were less likely to describe vertigo as the presenting symptom of BPPV compared to those in the younger group (OR = 0.22; 95% CI, 0. 12-0.41; p< 0. 001). The elderly group usually complained of imbalance and dizziness (OR = 15.83; 95% CI, 8.7-28.8; p<0. 001 and OR = 10.12; 95% CI, 5.23-19.59; p<0. 001, respectively). The duration of the symptom before diagnosis was longer in the elderly, when compared to the younger group (30 days, median; IQR = 7, 61 versus 5 days, median; IQR = 2, 7), respectively (p<0. 001). The ability to describe the trigger event precisely was less in the elderly group (63.8% versus 82.2%, p<0.001). The elderly group significantly underwent brain imaging studies more than the younger group (8.4% versus 3.5%, p = 0.02). Outcome of the treatment after the repositioning procedure was comparable in both groups (p = 0.58). Approximately 80% of patients in both groups had complete recovery from BPPV during their last visit.

• CONCLUSION: Dizziness and imbalance were the common presenting symptoms of BPPV in the elderly. The younger patients tended to describe the classic symptom of vertigo that was specific to BPPV more precisely than the elderly. These may contribute to underestimate BPPV, do unnecessary brain imaging study, and take more time to get the correct diagnosis of BPP V among elderly patients.

Geriatrics and BPPV studies cont.• BACKGROUND: Dizziness/vertigo is one of the most common complaint and handicapping condition among patients aged 65

years and older (Geriatric patients). This study was conducted to assess the impact of dizziness/vertigo on the quality of life in the geriatric patients attending a geriatric outpatient clinic.

• SETTINGS AND DESIGN: A cross-sectional study was performed in a geriatric outpatient clinic of a rural teaching tertiary care hospital in central India.

• MATERIALS AND METHODS: In all consecutive geriatric patients with dizziness/vertigo attending geriatric outpatient clinic, DHI questionnaire was applied to assess the impact of dizziness/vertigo and dizziness associated handicap in the three areas of a patients' life: physical, functional and emotional domain. Later, each patient was evaluated and underwent Dix-Hallpike maneuver by the physician who was blind of the DHI scoring of the patient.

• STATISTICAL ANALYSIS USED: We compared means and proportions of variables across two categories of benign paroxysmal positional vertigo (BPPV) and non-BPPV. For these comparisons we used Student's t-test to test for continuous variables, chi-square test for categorical variables and Fisher's exact test in the case of small cell sizes (expected value<5).

• RESULTS: The magnitude of dizziness/vertigo was 3%. Of the 88 dizziness/vertigo patients, 19 (22%) and 69(78%) cases, respectively, were attributed to BPPV and non-BPPV group. The association of DHI score ≥50 with the BPPV was found to be statistically significant with x(2) value = 58.2 at P<0.01.

• CONCLUSION: DHI Score is a useful tool for the prediction of benign paroxysmal positional vertigo. Correct diagnosis of BPPV is 16 times greater if the DHI Score is greater than or equal to 50. The physical, functional and emotional investigation of dizziness, through the DHI, has demonstrated to be a valuable and useful instrument in the clinical routine.