Tricks of Trade: Benign paroxysmal positional vertigo | Beyond the Basics

Clinical Case A 63-year old female presents to your ED with positional dizziness since rising out of bed from a nap this afternoon. She says she had a similar episode in the past and reports, “they took the stones out of my ear by making me lay down and move my head a few times.” Based on your assessment of the patient’s history and physical exam you determine she has peripheral vertigo, likely BPPV. However, despite multiple attempts with the Epley Maneuver, the patient is still symptomatic. What next steps could you consider? Benign paroxysmal positional vertigo: The basics Benign paroxysmal positional vertigo (BPPV) is a type of peripheral vertigo caused by a cluster of otoconial fragments that are displaced into the involved semicircular canal. The classic presentation is brief episodes of dizziness reported with position changes, commonly with rolling or arising from bed. The condition is more common in females and with advanced age (>40). BPPV should be differentiated from central vertigo and other types of peripheral vertigo including Meniere’s disease, vestibular schwannoma, vestibular neuritis, and labyrinthitis among others. Displaced otoliths are most commonly located in the posterior or horizontal semicircular canals. The strongest positive predictors of BPPV include dizziness lasting <15 seconds and onset with turning over in bed [1]. Episodes occur more frequently in the ear that is habitually dependent while sleeping [2], most commonly the right ear [3]. Regarding canal involvement, a retrospective review of 253 patients demonstrated the following [4]: 83% Unilateral posterior canal 7% Unilateral horizontal canal 6% Bilateral posterior canals 0% Anterior canal There exist many different diagnostics and therapeutic positional techniques for addressing BPPV. Below we discuss the commonly taught techniques and several viable alternatives to consider … Continue reading Tricks of Trade: Benign paroxysmal positional vertigo | Beyond the Basics