Fast Five Quiz: Annoying Medical Conditions

Richard H. Sinert, DO


April 25, 2022

BPPV is defined as an abnormal sensation of motion that is elicited by certain critical provocative positions. The provocative positions usually trigger specific eye movements (ie, nystagmus). The severity covers a wide spectrum. In patients with extreme cases, the slightest head movement may be associated with nausea and vomiting. Despite strong nystagmus, other patients seem relatively unfazed.

Classic BPPV is usually triggered by the sudden action of moving from the erect position to the supine position while angling the head 45° toward the side of the affected ear. Merely being in the provocative position is not enough; the head must move to the offending pose. After reaching the provocative position, a lag period of a few seconds occurs before the spell strikes. When BPPV is triggered, patients feel as though they are suddenly thrown into a rolling spin, toppling toward the side of the affected ear. Symptoms start very violently and usually dissipate within 20 or 30 seconds. This sensation is triggered again upon sitting erect; however, the direction of the nystagmus is reversed.

The onset of BPPV is typically sudden. Many patients wake up with the condition, noticing the vertigo while trying to sit up suddenly. Thereafter, propensity for positional vertigo may extend for days to weeks, occasionally for months or years. In many, the symptoms periodically resolve and then recur.

The physical examination findings in patients affected by BPPV are generally unremarkable. All neurotologic examination findings, except those from the Dix-Hallpike maneuver, may be normal. However, the presence of neurotologic findings does not preclude the diagnosis of BPPV. The Dix-Hallpike maneuver is the standard clinical test for BPPV. The finding of classic rotatory nystagmus with latency and limited duration is considered pathognomonic. A negative test result is meaningless except to indicate that active canalithiasis is not present at that moment.

The canalith repositioning procedure (CRP) is a simple and noninvasive office treatment that is designed to cure BPPV in 1-2 sessions. Because the benefit-to-risk ratio is so high, it appears to be the obvious first choice among treatment modalities. Surgery is usually reserved for those in whom CRP fails. It is not a first-line treatment because it is invasive and holds the possibility of complications such as hearing loss and facial nerve damage. Options include labyrinthectomy, posterior canal occlusion, singular neurectomy, vestibular nerve section, and transtympanic aminoglycoside application. All have a high chance of vertigo control. Complete destruction of the affected inner ear is excessive, considering that only the posterior semicircular canal is involved. Therefore, labyrinthectomy or vestibular nerve section should be reserved for the most extreme cases.

Learn more about BPPV.


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