Updated: 12/17/2021

Benign Paroxysmal Positional Vertigo (BPPV)

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Evidence
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  • Snapshot
    • A 65-year-old woman presents to her primary care phyisican for dizziness. Her symptoms began while lying in bed, and when she turned her head to the side she had an abnormal spinning sensation. The episode lasted for about 30 seconds and has occured multiple times over the course of the week. Her symptoms are associated with nausea. On physical exam, she had subjective vertigo and nystagmus with the Dix-Hallpike maneuver. She is treated with the Epley maneuver, which significantly improved her symptoms.
  • Introduction
    • Definition
      • inner ear disorder leading to spinning sensation exacerbated by head movement
  • Epidemiology
    • Incidence
      • more common in women
      • more common in the elderly
  • Etiology
    • Pathogenesis
      • anatomy
        • inner ear sensory hair cells detects endolymph movement with head or body motion
          • this causes the brain to perceive motion or position
            • rotation acceleration is detected by the semicircular canals
            • linear acceleration is detected by the utricle and saccule
      • canalithiasis (calcium debris) within the semicircular canal leads to improper motion of the endolymph, which results in a spinning sensation
        • most common site of canalithiasis is in the posterior semicircular canal
    • Idiopathic
    • Head trauma
    • Inner ear disease
    • Prolonged head immobility
  • Presentation
    • Symptoms
      • vertigo that lasts ≤ 1 minute
        • provoked by head movements
        • may be associated with nausea or vomiting
    • Physical exam
      • Dix-Hallpike maneuver
        • leads to vertigo and nystagmus when the affected ear is downwardly turned
        • suggests a canalith is in the posterior semicircular canal
      • Lateral head turn while supine (head-roll or log-roll test)
        • leads to vertigo and nystagmus when turned towards the affected side
        • suggests a canalith is in the lateral semicircular canal
  • Studies
    • Making the diagnosis
      • this is a clinical diagnosis
  • Differential
    • Meniere disease
      • differentiating factor
        • associated with sensorineural hearing loss and tinnitus
  • Treatment
    • Conservative
      • Epley maneuver
        • indication
          • treatment of choice to reposition the canalith
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(M2.ET.17.4774) A 28-year-old man presents to his primary care physician after experiencing intense nausea and vomiting yesterday. He states that he ran a 15-kilometer race in the morning and felt well while resting in a hammock afterward. However, when he rose from the hammock, he experienced two episodes of emesis accompanied by a sensation that the world was spinning around him. This lasted about one minute and self-resolved. He denies tinnitus or hearing changes, but he notes that he still feels slightly imbalanced. He has a past medical history of migraines, but he typically does not have nausea or vomiting with the headaches. At this visit, the patient’s temperature is 98.5°F (36.9°C), blood pressure is 126/81 mmHg, pulse is 75/min, and respirations are 13/min. Cardiopulmonary exam is unremarkable. Cranial nerves are intact, and gross motor function and sensation are within normal limits. When the patient’s head is turned to the right side and he is lowered quickly to the supine position, he claims that he feels “dizzy and nauseous.” Nystagmus is noted in both eyes. Which of the following is the best treatment for this patient’s condition?

QID: 109114
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Particle repositioning maneuver

83%

(24/29)

2

Thiazide diuretic

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3

Triptan therapy

3%

(1/29)

4

Meclizine

10%

(3/29)

5

Increased fluid intake

3%

(1/29)

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(M2.ET.16.4686) A 70-year-old women presents to her primary care physician with sudden episodes of dizziness that resolve in certain positions. On further questioning she describes a false sense of motion with occasional spinning sensation consistent with vertigo. She denies any recent illnesses or hearing loss aside from presbycusis. Her vital signs are normal. During the physical exam the the patient reports an episode of vertigo after transitioning from sitting to supine and horizontal nystagmus is concurrently noted. What is the mostly likely diagnosis?

QID: 107389
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Vestibular migraine

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Meniere's disease

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Labyrinthitis

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Benign Paroxysmal Positional Vertigo (BPPV)

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(3/3)

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Vestibular neuritis

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(M2.ET.14.4) A 60-year-old woman presents to the emergency department with dizziness. She states it started this morning when she woke up from bed and was severe causing her to vomit. The episode resolved in 1 minute. The patient has a past medical history of hypertension, diabetes, obesity, and atrial fibrillation treated with warfarin and metoprolol. She recently recovered from a cold a few days ago. Her temperature is 99.0°F (37.2°C), blood pressure is 174/99 mmHg, pulse is 115/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for a well appearing woman. Her neurological exam including cranial nerves and gait is within normal limits. The patient is laid flat in the bed which causes an episode of dizziness with notable nystagmus and vomiting. She feels better after 1 minute. The patient's ECG is seen in Figure A. Lab values are notable for an INR of 3.5. Which of the following is the most likely etiology of this patient's symptoms?

QID: 105004
FIGURES:
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Canalithiasis

8%

(8/95)

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Increased endolymph production

81%

(77/95)

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Inflammation of the vestibular apparatus

1%

(1/95)

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Inflammation of the vestibulocochlear apparatus

7%

(7/95)

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Vertebrobasilar insufficiency

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