Diagnosis & Treatment of BPPV Is Not Always Easy Two More Demanding Case Studies.

Dr John E FitzGerald Consultant Clinical Scientist Norfolk & Norwich University Hospital

Benign Paroxysmal Positional Vertigo (BPPV)- The Condition

Cause:
Otoconia from the gelatinous membrane of the utricle or saccule in the vestibular labyrinth of the inner ear, break free and reach the semicircular canals (most commonly the posterior semicircular canal (Lanska and Remler, 1997).

Benign Paroxysmal Positional Vertigo (BPPV)- The Condition

Certain position changes cause otoconia in the endolymph of the semicircular canal to move, resulting in a hydrodynamic drag effect, causing the cupula to be displaced, resulting in a change in neural firing rate, inducing a true rotational vertigo. (Canalithiasis hall et al, 1979). The subject feels a short duration dizziness.

Diagnosis
Presenting Symptoms

Short duration rotational vertigo when adopting specific positions, (rolling to the affected side in bed, rising from bed in the morning, looking up, lying down) Vertigo is of latent onset (however this may not always be noted by the patient) Vertigo adapts if the position is maintained

Diagnosis
A Positive Hallpike Manoeuvre
Rapidly move patient from a sitting position, with their head turned 45 to the right or left, to a lying position with the head tipped 45 below the horizontal A classical positive response is defined as a latent period before the onset of nystagmus; geotropic rotatory nystagmus with adaptation within 40 seconds (an upbeating vertical component is also sometimes evident) reversal of nystagmus on sitting up (not always evident) fatiguing of response on repeated manoeuvres duplication of the patients report of vertigo.

A positive response is attributed to the under most ear

Positive Response

Case 1.
A 56 year old man Referred by GP with a 6 month history of dizzy spells, especially when he puts his head back Seen in January 2003 for vestibular assessment

Symptoms:
Off work for several months TRV lasting 20seconds provoked by lying supine, rising from the supine, rolling left or right in bed. Last occurred morning of test. Left sided headaches, started at same time as dizziness (respond to headache tablets).

Hallpike Manoeuvre:
Right: Positive

Latent onset geotropic rotatory nystagmus with associated dizziness, adapted after approx. 10seconds BUT followed by an ageotropic rotatory nystagmus for a further 30seconds at least. On rising a vertical nystagmus was observed but this adapted. On repeat only a geotropic nystagmus was present which adapted and associated with less marked dizziness

Left: Positive

Latent onset more prominent geotropic rotatory nystagmus, showed adaptation after 60 seconds. Very dizzy and nauseous. Complete fatigue on repeat.

Conclusion:
Bilateral BPPV, worse on the left ear Due to nausea only a Left sided Epley was performed

1 week post treatment review

Considerable improvement on rising from bed Headaches diminished BUT dizziness still provoked by some movements ENG No spontaneous or gaze evoked nystagmus. Normal Smooth Pursuit & saccadic following

Hallpike Manoeuvre:
Left Positive Latent onset less prominent than previous week geotropic rotatory nystagmus, showed adaptation after 30 seconds. Dizzy. RightPositive Latent onset geotropic rotatory nystagmus with associated dizziness, BUT NO ageotropic rotatory nystagmus this week. Due to nausea the left Epley was conducted immediately from the supine position of the Hallpike. Right Epley also performed.

Further Reviews
3 weeks post treatment

Symptoms continue Headaches returned Positive Hallpikes left and right Breathless on rising from right Hallpike reported breathlessness on walking Worries about losing job

Further left Epley performed, referred for MRI to investigate central pathology and advised to seek cardiovascular and respiratory investigations (weight gain noticed). Referred back June 03 Diagnosed chronic obstructive airways disease (under treatment) Normal MRI (of IAMs)

Further Reviews
Reviews June 2003 - Sept 2003 Dizziness induced by rolling to left side, looking up, rising from bed in morning. Feeling of loosing consciousness & sometimes wooziness lasting all day. Right Hallpike: Classic positive findings. Left Hallpike : Negative. Repeat Right Epley Manoeuvres (x 3 occasions). Brandt Daroff Exercises. Discharged accepting some improvement, but no complete recovery.

Case 1 Right Hallpike (June 2004)

10 Second latent onset AGEOTROPIC rotatory nystagmus Duration 20 seconds On rising Nil Testing stopped due to nausea
Eyes Up Patient Eyes left Patient Eyes Right Eyes Down N.B. Image is a mirror reflection of patient

Take a Valium!
5mg 2 hours before appointment 5mg before being seen Advice on driving!

Case 1 Right Hallpike (Sept 04)

Latent Onset Short duration dizziness ? Horizontal Nystagmus ?Vertical Nystagmus Geotropic rotatory nystagmus Adapts within 20 seconds
Eyes Up Patient Eyes left Patient Eyes Right Eyes Down N.B. Image is a mirror reflection of patient

Case 1 Right Hallpike

Geotropic rotatory nystagmus Adapts On Rising Downbeating vertical nystagmus Adapts
Eyes Up Patient Eyes left Eyes Down N.B. Image is a mirror reflection of patient Patient Eyes Right

Case 1 - Conclusions
Nystagmus is of a peripheral origin Latent Onset Adaptation Partial Fatigue Reversal from upbeating to downbeating on rising Where are the otoconia? Posterior canal? Horizontal Canal? Anterior Canal?

Case 2 - History
A 71year old lady 2 year history of TRV lasting seconds Provoked by turning in bed either side, sitting up, looking up, and general head movements Latent onset reported

Case 2. Left Hallpike - down

Geotropic rotatory nystagmus BUT NO adaptation after at least 80 seconds

Eyes Up Patient Eyes left Patient Eyes Right Eyes Down N.B. Image is a mirror reflection of patient

Case 2. Left Hallpike - Up

Vertical downbeating nystagmus BUT NO adaptation

Eyes Up Patient Eyes left Eyes Down N.B. Image is a mirror reflection of patient Patient Eyes Right

Case 2. Right Hallpike - Down

AGEOTROPIC rotatory nystagmus No adaptation within 60seconds Latent onset

Eyes Up Patient Eyes left Patient Eyes Right Eyes Down N.B. Image is a mirror reflection of patient

Case 2. Right Hallpike - Up

Vertical Downbeating Nystagmus NO ADAPTATION

Eyes Up Patient Eyes left Patient Eyes Right Eyes Down N.B. Image is a mirror reflection of patient

Test Indications
Central Pathology Why? Lack of adaptation of geotropic rotatory nystagmus in left Hallpike Ageotropic rotational nystagmus in right Hallpike with lack of adaptation. Maintained downbeating nystagmus on rising from both sides

Case 2 Other Test Results

Downbeating vertical spontaneous nystagmus Also present with left gaze, and down gaze Enhanced with rightward gaze Abolished with upward gaze Caloric test: Balanced warm water irrigations MRI: No CPA Lesion Ventricles normal size and shape, not displaced. No intra-cranial abnormality

Case 2 Possible Indications

Central Problem Lower Medullary Infarction (due to enhancement of downbeating vertical nystagmus with lateral gaze, and abolition on upward gaze)

Summary
Consider Valium to help complete tests and possible treatment. Look for reversal of nystagmus on changing position Other tests should always be used in conjunction with Hallpike Manoeuvre when nonstandard results obtained Cant treat everyone