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benign positional vertigo; benign paroxysmal positional vertigo

Brief episodic vertigo or sensation of spinning associated with changes in head position, especially when supine or recumbent. It is the most common cause of peripheral vertigo. Etiology: 1) post-traumatic. i.e. head injury (generally within a few days) 2) post viral neurolabyrinthitis (generally 1-8 weeks after) 3) particles trapped in the posterior semicircular canal 4) ostepenia & osteoporosis are risk factors [11,12] 5) idiopathic (50%) Epidemiology: 1) most common cause of peripheral vertigo 2) particularly common in the elderly 3) idiopathic a) peaks in 6th decade b) female:male ratio is > 2:1 Pathology: 1) basophilic deposits on the cupulae of the posterior semicircular canals (unilateral) 2) these basophilic deposits are otoconia released from a degenerating utricular macule 3) the otoconia settle on the cupula of the posterior semicircular canal (situated directly under the utricular macule in the sitting position) causing it to become heavier than the surrounding endolymph 4) when the patient's head changes position, the position of the posterior semicircular canal changes 5) a utriculofugal displacement of the cupula occurs in response to a superior displacement of the posterior semicircular canals, with a resultant burst of nystagmus & positional vertigo [6] History: 1) sensation of spinning 2) dizziness with head movement 3) duration of dizziness < 3 minutes * sensitivity & specificity of positive response to all 3 elements of history 87% & 90%, respectively [16] Clinical manifestations: 1) generally intermixed with variable periods of remission 2) periods or vertigo rarely last > 1 minute, generally 10-30 seconds 3) may be flurry of episodes 4) symptoms are generally precipitated by head movements or changes in position a) looking up b) episode of vertigo while reaching for something high on a shelf c) rolling over in bed d) getting up from bed (supine to sitting) e) may be a latency between positional change & vertigo [20] 5) sensation of spinning 6) blurred vision & diplopia suggest neurologic etiology [14,18] 7) autonomic symptoms are common a) nausea/vomiting b) sweating c) pallor d) vasovagal syncope 8) slow resolution in weeks to months in most patients 9) Dix-Hallpike maneuver for nystagmus a) fatigable paroxysmal positional nystagmus - rotatory nystagmus lasts < 1 minute [15] b) primarily torsional, vertical with minimal horizontal component c) the upper pole of the eye beats towards the undermost ear - upbeat torsional nystagmus [21] d) may be a latency between positional change & nystagmus - case presentation - 5 seconds [23] e) horizontal & torsional nystagmus fatigues after 1 minute [20] f) upbeat-torsional nystagmus diagonally toward undermost ear, lasts < 1 minute 10) Rhomberg test would only be positive during episodes of vertigo Laboratory: none necessarily indicated, (see vertigo) Radiology: routine imaging unnecessary [4] Differential diagnosis: - viral labyrinthitis (hearing loss & duration of symptoms > 24 hours) - vestibular neuronitis - may follow an upper respiratory tract infection, Herpes simplex - non-positional, positive Rhomberg test - ear pain, tinnitus may be noted - duration of symptoms > 24 hours (constant) - Meniere's disease - hearing loss, tinnitus, duration of symptoms: 15 minutes-24 hours Management: 1) pharmacologic therapy generally not useful a) meclizine (GRS10 seems to implicate meclizine is useful) [11] b) clonazepam [4] c) prochlorperazine [4] d) phenergan 2) habituation exercises a) may lessen severity & frequency b) single maneuver may suffice, but frequently multiple or regular exercises are necessary [7] c) many patients do not tolerate eliciting symptoms d) Epley procedure is maneuver of choice [7,8,11] - canalith repositioning procedure [5] e) Brandt-Daroff exercise - has not been shown to be as effective as 'in-office' Epley maneuver [11] 3) symptoms spontaneously remit in most patients 4) surgery (section of ampullary nerve from the posterior canal) for intractable symptoms

Related

ampullary nerve Brandt-Daroff exercise canalith repositioning procedure Dix-Hallpike maneuver Epley procedure/maneuver (canalith repositioning) semicircular canal

General

peripheral vertigo

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1013-15
  2. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 648
  3. Journal Watch, Mass Med Soc 19(23):186 (Dec) 1999
  4. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018, 2021.
  5. Journal Watch, Mass Med Soc 20(17):139 (Sept) 2000
  6. Baloh RW Dizziness in older people. J Am Geriatric Soc 40:713, 1992 PMID: 1607589
  7. Journal Watch 24(17):136, 2004 Radtke A, von Brevern M, Tiel-Wilck K, Mainz-Perchalla A, Neuhauser H, Lempert T. Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure. Neurology. 2004 Jul 13;63(1):150-2. PMID: 15249626 http://www.neurology.org/cgi/content/full/63/1/150
  8. Tanimoto H, Doi K, Katata K, Nibu KI. Self-treatment for benign paroxysmal positional vertigo of the posterior semicircular canal. Neurology. 2005 Oct 25;65(8):1299-300. PMID: 16247062
  9. Bhattacharyya N et al Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008 Nov;139(5 Suppl 4):S47-81. PMID: 18973840
  10. Fife TD, Iverson DJ, Lempert T et al Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008 May 27;70(22):2067-74 PMID: 18505980
  11. Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019
  12. Jang YS, Kang MK. Relationship between bone mineral density and clinical features in women with idiopathic benign paroxysmal positional vertigo. Otol Neurotol. 2009 Jan;30(1):95-100 PMID: 19008769 - Jeong SH, Choi SH, Kim JY, Koo JW, Kim HJ, Kim JS. Osteopenia and osteoporosis in idiopathic benign positional vertigo. Neurology. 2009 Mar 24;72(12):1069-76. PMID: 19307540 - Mikulec AA, Kowalczyk KA, Pfitzinger ME et al Negative association between treated osteoporosis and benign paroxysmal positional vertigo in women. J Laryngol Otol. 2010 Apr;124(4):374-6. PMID: 19930786
  13. Cho EI, White JA. Positional vertigo: as occurs across all age groups. Otolaryngol Clin North Am. 2011 Apr;44(2):347-60, viii PMID: 21474009
  14. Kim JS, Zee DS. Benign paroxysmal positional vertigo. N Engl J Med. 2014;370:1138-1147 PMID: 24645946
  15. NEJM Knowledge+ Question of the Week. Feb 19, 2019 https://knowledgeplus.nejm.org/question-of-week/1346
  16. Kim HJ, Song JM, Zhong L, Yang X Questionnaire-based diagnosis of benign paroxysmal positional vertigo. Neurology 2020 Mar 3; 94:e942 PMID: 31888973 https://n.neurology.org/content/94/9/e942
  17. Kim HJ, Park J, Kim JS. Update on benign paroxysmal positional vertigo. J Neurol. 2021 May;268(5):1995-2000. PMID: 33231724 PMCID: PMC7684151 Free PMC article https://link.springer.com/article/10.1007/s00415-020-10314-7
  18. Hoffman RM, Einstadler D, Kroenke K Evaluating dizziness. Am J Med 1999; 107(5);468-478 PMID: 10569302
  19. Kneisel K Web-Based System Shows Benefits for Recurrent Benign Positional Vertigo. "The first time I experienced it, I thought I had woken up to an earthquake," expert says. MedPage Today January 17, 2023 https://www.medpagetoday.com/neurology/generalneurology/102663 - Kim HJ, Kim JS, Choi KD et al Effect of Self-treatment of Recurrent Benign Paroxysmal Positional Vertigo. A Randomized Clinical Trial. JAMA Neurol. Published online January 17, 2023 PMID: 36648931 https://jamanetwork.com/journals/jamaneurology/fullarticle/2800168
  20. NEJM Knowledge+ Neurology
  21. NEJM Knowledge+ Otolaryngology
  22. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg. 2017;156:S1-S47. PMID: 28248609
  23. Balatsouras DG, Koukoutsis G, Fassolis A, Moukos A, Apris A. Benign paroxysmal positional vertigo in the elderly: current insights. Clin Interv Aging. 2018 Nov 5;13:2251-2266. PMID: 30464434 PMCID: PMC6223343 Free PMC article. Review.