Benign Paroxysmal Positional Vertigo

BPPV Basics - Crystal Chaos

• Definition: Vestibular disorder: recurrent, brief vertigo with head position changes. Caused by otoconia (calcium carbonate crystals) displaced from utricle into semicircular canals.
• Epidemiology: Most common peripheral vertigo, especially in older adults.
• Pathophysiology:
  • Otoconia ("ear rocks") from the utricle dislodge.
  • Posterior Semicircular Canal (PSC) most affected due to gravity. 📌 Mnemonic: "P"osterior & "P"opular.
• Types:
  • Canalithiasis: Free-floating otoconia in canal endolymph (more common).
  • Cupulolithiasis: Otoconia adhere to the cupula (rarer, more persistent).

⭐ The posterior semicircular canal is most frequently affected in BPPV (approx. 80-90% of cases) due to its gravity-dependent position, facilitating otoconial settlement.

Clinical Clues - Spin Signals

• Vertigo Profile:
  • Sudden, recurrent, brief episodes: <1 minute.
  • Triggers: Specific head position changes (e.g., rolling in bed, looking up/down, bending over).
• Associated Symptoms:
  • Nausea/vomiting common.
  • ABSENT: Hearing loss, tinnitus, ear fullness, or focal neurological deficits. (Key differentiator!)
• Diagnostic Maneuvers & Nystagmus:
  • Dix-Hallpike Test (for Posterior/Anterior Canals - PSC/ASC):
    • Procedure: Patient rapidly moved from sitting to supine with head extended (30-45°) and turned 45° to one side.
    • Positive (PSC BPPV): Latency (2-20 seconds), then characteristic nystagmus (torsional: rotatory towards affected/downward ear; vertical: upbeating). Nystagmus is fatigable with repetition and lasts <1 minute.
  • Supine Roll Test (Pagnini-McClure Maneuver) (for Horizontal Canal - HSC):
    • Procedure: Patient supine, head flexed 20-30°, head rapidly turned 90° to each side.
    • Nystagmus:
      • Geotropic: Horizontal nystagmus, beats towards the ground (indicates canalithiasis). Stronger on the affected side.
      • Ageotropic: Horizontal nystagmus, beats towards the sky/ceiling (indicates cupulolithiasis). Weaker on the affected side.

⭐ The classic nystagmus of posterior canal BPPV elicited by Dix-Hallpike is upbeating and torsional (towards the affected ear), with a latency of a few seconds and duration less than one minute.

Treatment Tactics - Stone Settlers

Mainstay: Canalith Repositioning Procedures (CRPs) - Relocate displaced otoconia.

• Epley Maneuver: For Posterior Canal (PSC) canalithiasis. High success (e.g., >80%).
• Semont Maneuver: For PSC cupulolithiasis/canalithiasis.
• HSC Maneuvers:
  • Barbecue Roll (Lempert): HSC geotropic canalithiasis.
  • Gufoni/Appiani: HSC geotropic/apogeotropic variants.

Other Options:

• Brandt-Daroff Exercises: Home exercises for residual symptoms or as alternative (less effective primary).
• Pharmacotherapy (Limited): Symptomatic relief for severe nausea/vertigo (antiemetics, short-term vestibular suppressants). Not curative.
• Surgery (Rare): For intractable cases (e.g., singular neurectomy, canal plugging).

⭐ The Epley maneuver is the most widely used and effective treatment for posterior canal BPPV (canalithiasis).

Beyond BPPV - Vertigo Variants

• Differential Diagnoses (DDx):
  • Migrainous vertigo: Migraine Hx, assoc. symptoms.
  • Central (VBI, stroke): ⚠️ Red flags: persistent nystagmus, new neuro deficits (diplopia, ataxia).

Key Distinctions Table:

*   Prognosis: Excellent with CRPs. Recurrence **15-20%**/year.
*   Complications: Falls, anxiety, residual dizziness.

⭐ BPPV typically does not cause hearing loss or tinnitus, unlike Meniere's disease or vestibular neuritis.

High-Yield Points - ⚡ Biggest Takeaways

• BPPV: Most common cause of recurrent vertigo.
• Pathophysiology: Canalithiasis (free-floating otoconia) in semicircular canals, predominantly posterior canal (PSC).
• Clinical: Sudden, brief episodes of vertigo (seconds to < 1 minute), provoked by changes in head position.
• Diagnosis: Dix-Hallpike maneuver elicits characteristic torsional/rotatory nystagmus (latency, fatigable, transient).
• Treatment: Canalith Repositioning Procedures (CRP), e.g., Epley maneuver for PSC BPPV.
• Key differentiator: No associated hearing loss or tinnitus (distinguishes from Meniere's disease).