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VERTIGO                                                See also vestibularneuritis.htm  |  BPV.mht  | BPV2009.mht  


Benign positional vertigo (BPV) is the most common cause of vertigo.

Vertigo is an illusion of motion (an illusion is a misperception of a real stimulus) and represents a disorder of the vestibular proprioceptive system. VERTIGO IS A HALLUCINATION OF SELF- OR ENVIRONMENTAL MOVEMENT,
MOST COMMONLY A FEELING OF SPINNING, USUALLY DUE TO A DISTURBANCE IN THE VESTIBULAR SYSTEM.

Differentiation of Peripheral and Central vertigo:

Sx

Peripheral (labyrinth)

Central (brainstem or cerebellum)
Tinnitus/deafness Often present Usually absent
Assoc.central abnormallity None Extremely common
Severity of vertigo Marked Usually mild
Nystagmus:
Direction		 Unidirectional; fast phase
-opposite lesion		 Bidirectional or uni-
Purely horizontal nystagmus
component		 Uncommon Common without torsional
Vertical or purely torsional
component		 Never present May be present
Visual Fixation Inhibits nystagmus/vertigo No inhibition
Common Causes Infectious labyrhintitis,
Meniere's, neuronitis, toxin,
ischemia, trauma		 Vascular, demyelinating, neoplasm
Duration of Sx Finite(min to wks),may recur May be chronic

The standard test for vestibular function is ENG (Electronystagmography), where warm & cold water is applied to the tympanic membranes, & the nystagmus pattern is studied.

A.  VERTIGO:

  1. ~90% are vestibular
  2. Peripheral Vertigo (40%)
  3. Central Vertigo
  4. Audiometry is helpful to distinguish
  5. Nystagmus

B. Presyncope / Syncope

C. Dysequilibrium

  1. Peripheral neuropathy
  2. Previous Stroke
  3. Arthritis
  4. Parkinson's Disease

D. Mental Status Changes

E. Psychiatric Disease (~20%)

Differential Diagnoses of Benign paroxysmal positional vertigo (BPPV)

Other Problems to Be Considered in BPPV

The Dix-Hallpike Testing Maneuver picture  |  Video of the Maneuver  

The modified Epley Maneuver picture  

        

RX of acute vertigo:
bedrest & vestibular suppressant drugs as: meclizine, dimenhydrinate, promethazine, scopolamine, diazepam.

If the Sx persists beyond a few days, most authorities advise ambulation in an attempt to induce central compensatory mechanisms, despite the short-term discomfort to the pt.

Chronic vertigo of labyrinthine origin may be treated with a systematized exercise program to faciliate compensation.


Differential Diagnosis of Acute Vertigo:

Labyrinthine vertigo:

Vestibular Vertigo (vestibular nerve origin):

Vestibular neuronitis & benign recurrent vertigo (unknown cause):

RX: as in Meniere's Disease.

Acute unilateral labyrinthine dysfunction is idiopathic, or caused by infection, trauma, & ischemia.

Acute bilateral labyrinthine dysfunction is usually the result of toxins, drugs or alcohol.

Acoustic neuroma (The eight cranial nerve Schwannomas) grows slowly & produce such a gradual reduction of labyrinthine output that central compensatory mechanisms prevent or minimize the vertigo; auditory Sx of hearing loss & tinnitus are the most common Sx.

Recurrent unilateral labyrinthine dysfunction with cochlear disease (tinnitus/deafness) is usually due to Meniere's disease.

Recurrent unilateral labyrinthine dysfunction without auditory Sx is called vestibular neuronitis.

TIA of posterior cerebral circulation (vertebrobasilar insufficiency) almost never cause recurrent vertigo without concomitant motor, sensory, visual, cranial nerve, or cerebellar signs.

Positional vertigo is precipitated by a recumbent head position (not just the head movement), either to the right or to the left.

Benign paroxysmal positional vertigo (BPPV) is particularly common. It generally abates spontaneously after weeks or months. Its nystagmus pattern is distinctive. The lower eye displays a large-amplitude torsional nystagmus, & the upper eye has a lesser degree of torsion combined with upbeating nystagmus. If the eyes are directed to the upper ear, the vertical nystagmus in the upper eye increases in amplitude.

Psychogenic vertigo, usually a concomitant of agoraphobia (fear of large open spaces, crowds, or leaving the safety of home) should be suspected in pts so "incapacitated' by their Sx that they adopt a prolonged housebound status. It has no nystagmus during a vertiginous episode.

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MENIERE'S DISEASE OR SYNDROME:              
Recurrent vertigo associated with tinnitus & progressive deafness.
The pathological changes are said to consist of a dilatation of the endolymphatic system which leads to a degeration of the delicate bestibular & cochlear hair cells.

RX:
During acute attack, rest in bed is the most effective Rx.
Meclizine, demenhydrinate, cyclizine 25-50 mg tid is useful in treating more protracted attacks.
Mild sedative drugs may help the anxious pt between attacks.
Usually the deafness is unilateral & progressive, & when it is complete, the vertiginous sttacks cease. However, the course is variable.

BENIGN POSITIONAL VERTIGO
Occurence of paroxysmal vertigo & nystagmus with the assumption of certain critical positions of the head, secondary to labyrinthine dysfunction.

RX:

  1. Medication: meclizine 25 mg tid, dimenhydrinate, promethazine, scopolamine, diazepam.
  2. Epley's Particle-repositioning maneuver:  The modified Epley Maneuver picture
    The patient is rapidly placed into the provocative supine position.  The patient's neck is hyperextended, & is tolled 2700 toward the contrlateral ear until the face-down position is reached.  The maneuver is done over a 2-minute period, often with the assistance of a vibrator positioned over the involved temporal bone.  The patient is then returned to a sitting position. Patient is instructed to avoid lying flat, hyperextending the neck, or bending over for the following 36 hours.  This maneuver is remarkably successful in most cases.  Patients can learn to do the maneuver at home & repeat it as necessary.
    [The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo.  
    Epley JM: Portland Otologic Clinic, OR 97213.
    Otolaryngol Head Neck Surg 1992 Sep;107(3):399-404
    ABSTRACT:
    The Canalith Repositioning Procedure (CRP) is designed to treat benign paroxysmal positional vertigo (BPPV) through induced out-migration of free-moving pathological densities in the endolymph of a semicircular canal, using timed head maneuvers and applied vibration. This article describes the procedure and its rationale, and reports the results in 30 patients who exhibited the classic nystagmus of BPPV with Hallpike maneuvers. CRP obtained timely resolution of the nystagmus and positional vertigo in 100%.   Of these, 10% continued to have atypical symptoms, suggesting concomitant pathology; 30% experienced one or more recurrences, but responded well to retreatment with CRP. These results also support an alternative theory that the densities that impart gravity-sensitivity to a semicircular canal in BPPV are free in the canal, rather than attached to the cupula. CRP offers significant advantages over invasive and other noninvasive treatment modalities in current use.]

REF: Harrison 1994                                                                                      

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REVIEW - Primary Care: Benign Paroxysmal Positional Vertigo - J. M. Furman and S. P. Cass
NEJM Volume 341, Number 21: November 18, 1999
Motion Sickness  [Paul M. Gahlinger, MD  VOL 106 / NO 4 / OCTOBER 1, 1999 / POSTGRADUATE MEDICINE]

Dizziness among Older Adults: A Possible Geriatric Syndrome - Mary Tinetti
Annals of Internal Medicine, 7 March 2000. 132:337-44.


Maneuvers for benign positional vertigo
VOL 105 / NO 5 / MAY 1, 1999 / POSTGRADUATE MEDICINE

Q: Do the maneuvers I've heard about to treat benign positional vertigo really work? How are they performed? Can patients be taught to do them at home?          Epley's Particle-repositioning maneuver:  The modified Epley Maneuver picture

A: Benign paroxysmal positional vertigo is a self-limited vestibular disorder characterized by vertigo and nystagmus that are provoked by a change in position. Pathophysiology entails displacement of otoconia (calcium carbonate crystals) that are normally adherent to the utricle and saccule within the vestibule. These particles can float to the dependent portion of the posterior semicircular canal and become lodged. Head movements (eg, neck hyperextension or supine positioning toward the involved ear) cause the particles to move, due to gravitational forces, and induce flow of inner ear endolymph. This stimulates the inner ear, creating the sensation of vertigo with associated upward and rotary nystagmus.  

In the particle-repositioning maneuver, described by Epley,1 the patient is rapidly placed into the provocative supine position. The patient's neck is hyperextended, and he or she is rolled 270° toward the contralateral ear until the face-down position is reached. The maneuver is done over a 2-minute period, often with the assistance of a vibrator positioned over the involved temporal bone. The patient is then returned to a sitting position. Patients are instructed to avoid lying flat, hyperextending the neck, or bending over for the following 36 hours.

This maneuver is remarkably successful in most cases. In about one third of patients, symptoms recur after a few years, but patients can learn to do the maneuver at home and repeat it as necessary.

Vestibular-rehabilitation exercises have been successful in achieving relief of symptoms by habituation in patients who do not respond to the maneuver.  

References
Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107(3):399-404

Barry E. Hirsch, MD Associate Professor Department of Otolaryngology, University of Pittsburgh School of Medicine

See also Mayo Clin Proc July 2000;75:695 - David Froehling, etc  The Canalith Repositiong Procedure

The dizzy patient - Presence of vertigo points to vestibular cause - Robert W. Baloh (UCLA)
VOL 105 / NO 2 / FEBRUARY 1999 / POSTGRADUATE MEDICINE  

Decision Making in Medicine: Dizzy Patients: The Varieties of Vertigo   -Robert W. Baloh (UCLA)
Hosp Pract 1998 June

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