benign positional vertigo; benign paroxysmal positional vertigo
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Introduction
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
- post-traumatic. i.e. head injury (generally within a few days)
- post viral neurolabyrinthitis (generally 1-8 weeks after)
- particles trapped in the posterior semicircular canal
- ostepenia & osteoporosis are risk factors[11][12]
- idiopathic (50%)
Epidemiology
- most common cause of peripheral vertigo
- particularly common in the elderly
- idiopathic
- peaks in 6th decade
- female:male ratio is > 2:1
Pathology
- basophilic deposits on the cupulae of the posterior semicircular canals (unilateral)
- these basophilic deposits are otoconia released from a degenerating utricular macule
- 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
- when the patient's head changes position, the position of the posterior semicircular canal changes
- 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
* sensitivity & specificity of positive response to all 3 elements of history 87% & 90%, respectively[16]
Clinical manifestations
- generally intermixed with variable periods of remission
- periods or vertigo rarely last > 1 minute, generally 10-30 seconds
- may be flurry of episodes
- symptoms are generally precipitated by head movements or changes in position
- sensation of spinning
- blurred vision & diplopia suggest neurologic etiology[14][18]
- autonomic symptoms are common
- slow resolution in weeks to months in most patients
- Dix-Hallpike maneuver for nystagmus
- fatigable paroxysmal positional nystagmus
- primarily torsional, vertical with minimal horizontal component
- the upper pole of the eye beats towards the undermost ear
- may be a latency between positional change & nystagmus
- case presentation - 5 seconds[23]
- horizontal & torsional nystagmus fatigues after 1 minute[20]
- upbeat-torsional nystagmus diagonally toward undermost ear, lasts < 1 minute
- 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
- pharmacologic therapy generally not useful
- meclizine (GRS10 seems to implicate meclizine is useful)[11]
- clonazepam[4]
- prochlorperazine[4]
- phenergan
- habituation exercises
- may lessen severity & frequency
- single maneuver may suffice, but frequently multiple or regular exercises are necessary[7]
- many patients do not tolerate eliciting symptoms
- Epley procedure is maneuver of choice[7][8][11]
- Brandt-Daroff exercise
- has not been shown to be as effective as 'in-office' Epley maneuver[11]
- symptoms spontaneously remit in most patients
- surgery (section of ampullary nerve from the posterior canal) for intractable symptoms
More general terms
Additional terms
- ampullary nerve
- Brandt-Daroff exercise
- canalith repositioning procedure
- Dix-Hallpike maneuver
- Epley procedure/maneuver (canalith repositioning)
- semicircular canal
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1013-15
- ↑ Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 648
- ↑ Journal Watch, Mass Med Soc 19(23):186 (Dec) 1999
- ↑ 4.0 4.1 4.2 4.3 Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2012, 2015, 2018, 2021.
- ↑ 5.0 5.1 Journal Watch, Mass Med Soc 20(17):139 (Sept) 2000
- ↑ 6.0 6.1 Baloh RW Dizziness in older people. J Am Geriatric Soc 40:713, 1992 PMID: https://www.ncbi.nlm.nih.gov/pubmed/1607589
- ↑ 7.0 7.1 7.2 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. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/15249626 <Internet> http://www.neurology.org/cgi/content/full/63/1/150
- ↑ 8.0 8.1 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: https://www.ncbi.nlm.nih.gov/pubmed/16247062
- ↑ Bhattacharyya N et al Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008 Nov;139(5 Suppl 4):S47-81. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18973840
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/18505980
- ↑ 11.0 11.1 11.2 11.3 11.4 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 - ↑ 12.0 12.1 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: https://www.ncbi.nlm.nih.gov/pubmed/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: https://www.ncbi.nlm.nih.gov/pubmed/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: https://www.ncbi.nlm.nih.gov/pubmed/19930786 - ↑ Cho EI, White JA. Positional vertigo: as occurs across all age groups. Otolaryngol Clin North Am. 2011 Apr;44(2):347-60, viii PMID: https://www.ncbi.nlm.nih.gov/pubmed/21474009
- ↑ 14.0 14.1 Kim JS, Zee DS. Benign paroxysmal positional vertigo. N Engl J Med. 2014;370:1138-1147 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24645946
- ↑ 15.0 15.1 NEJM Knowledge+ Question of the Week. Feb 19, 2019 https://knowledgeplus.nejm.org/question-of-week/1346
- ↑ 16.0 16.1 Kim HJ, Song JM, Zhong L, Yang X Questionnaire-based diagnosis of benign paroxysmal positional vertigo. Neurology 2020 Mar 3; 94:e942 PMID: https://www.ncbi.nlm.nih.gov/pubmed/31888973 https://n.neurology.org/content/94/9/e942
- ↑ Kim HJ, Park J, Kim JS. Update on benign paroxysmal positional vertigo. J Neurol. 2021 May;268(5):1995-2000. PMID: https://www.ncbi.nlm.nih.gov/pubmed/33231724 PMCID: PMC7684151 Free PMC article https://link.springer.com/article/10.1007/s00415-020-10314-7
- ↑ 18.0 18.1 Hoffman RM, Einstadler D, Kroenke K Evaluating dizziness. Am J Med 1999; 107(5);468-478 PMID: https://www.ncbi.nlm.nih.gov/pubmed/10569302
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/36648931 https://jamanetwork.com/journals/jamaneurology/fullarticle/2800168 - ↑ 20.0 20.1 20.2 NEJM Knowledge+ Neurology
- ↑ 21.0 21.1 NEJM Knowledge+ Otolaryngology
- ↑ 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: https://www.ncbi.nlm.nih.gov/pubmed/28248609
- ↑ 23.0 23.1 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: https://www.ncbi.nlm.nih.gov/pubmed/30464434 PMCID: PMC6223343 Free PMC article. Review.