Case 37: Dizziness
Iqbal Khan in Medical Histories for the MRCP and Final MB, 2018
There is a sense of spinning of either the patient (subjective vertigo) or the environment (objective vertigo). It is usually associated with nystagmus and is often related to problems with the vestibular system. Causes include the following.Ménière’s disease: excessive build up of fluid in the inner ear.Inflammation of the inner ear, e.g. associated with acute vestibular neuronitis, or labyrinthitis.Benign paroxysmal positional vertigo (BPPV): the vertigo is associated with a change in head position.Acoustic neuroma.Vestibular migraine.
Cranial Neuropathies I, V, and VII–XII
Philip B. Gorelick, Fernando D. Testai, Graeme J. Hankey, Joanna M. Wardlaw in Hankey's Clinical Neurology, 2020
Benign paroxysmal positional vertigo (BPPV): this is a common inner ear disorder characterized by brief attacks of vertigo precipitated by head movement and associated with nystagmus and autonomic symptoms. The vertigo typically lasts < 30 seconds. Symptoms may occur repeatedly throughout the day. BPPV is due to canalithiasis (otoconia dislodge from the macule of the utricle and become free floating in a SCC) or cupulolithiasis (otoconia become adherent to the matrix gel of the cupula). Most cases of BPPV are due to posterior canalithiasis. The diagnosis of BPPV is confirmed with the Dix–Hallpike maneuver. In posterior canal BPPV, after head tilt toward the affected ear, vertigo develops with concomitant nystagmus with an upbeat and torsional component. The nystagmus develops a few seconds after positioning the patient, fatigues within 30 seconds, and habituates with repeated attempts. Symptoms may last for weeks and may recur.39 With a central lesion, symptoms develop when the head is turned to either side during the testing maneuver; the vertigo is usually mild and brief; the nystagmus changes direction when the head is turned from one side to the other, and is not fatigable. Treatment of BPPV consists of repositioning maneuvers40 (Epley's and Semont's maneuvers).
Practice Paper 3: Answers
Anthony B. Starr, Hiruni Jayasena, David Capewell, Saran Shantikumar in Get ahead! Medicine, 2016
Benign paroxysmal positional vertigo (BPPV) occurs secondary to degeneration of the utricular neuroepithelium in the semicircular canals. This may be spontaneous or occur after head injury. The degenerate material affects the free flow of endolymph in the labyrinth. Attacks of vertigo are precipitated by turning the head so that the affected ear is undermost (the vertigo appears after a latent period and is brief). Affected patients become reluctant to move their heads. Diagnosis of BPPV is by the Hallpike test: the patient is sat upright with the legs extended, the head is rotated 45°, then the patient is made to lie down quickly and the head held in extension. The patient’s eyes are then observed. A positive test will result in nystagmus towards the affected side after a 5–10-second latent period.
Analysis of Dix-Hallpike maneuver induced nystagmus based on virtual simulation
Published in Acta Oto-Laryngologica, 2021
Yanyan Zheng, Shuzhi Wu, Xiaokai Yang
Benign positional paroxysmal vertigo (BPPV) is a disorder of the inner ear characterized by recurrent transient vertigo induced by changes in head position relative to the direction of gravity and is one of the most common causes of vertigo. The Dix-Hallpike maneuver is the gold standard for diagnosing BPPV of vertical semicircular canals [1]. Since the Dix-Hallpike maneuver can induce otoliths movement in almost all semicircular canals, even inducing otoliths from the utricle into the semicircular canals, the nystagmus can take various forms, including horizontal nystagmus, torsional nystagmus with a vertical upward component or vertical downward component, and vertical nystagmus alone. How to interpret the nystagmus induced by the Dix-Hallpike maneuver has been the hotspot and difficulty of research [2–5].
Low 25-hydroxyvitamin D levels in postmenopausal female patients with benign paroxysmal positional vertigo
Published in Acta Oto-Laryngologica, 2018
Weiwei Han, Zhenyi Fan, Min Zhou, Xu Guo, Wang Yan, Xiaoxiong Lu, Li Li, Chengyao Gu, Caijing Chen, Yunqin Wu
Benign paroxysmal positional vertigo (BPPV) is one of the most common forms of vertigo. Although the mechanism of otoconial degeneration and detachment from otoconial beds remains unknown, the widely accepted opinion is that BPPV is caused by dislodged otoconia floating into one of the semicircular canals, thereby making them sensitive to gravity [1]. BPPV can develop in the setting of head trauma, vestibular neuritis, migraines, Meniere’s disease, or ear surgery, but for 50 to 70% of BPPV cases, the aetiology is still unknown and is referred to as idiopathic. BPPV can occur at any age, but the incidence increases with age. The 1-year prevalence of individuals with BPPV ranges from 0.5% in 18- to 39-year-olds to 3.4% in individuals above 60 years old [1,2]. Idiopathic BPPV is predominant in females above 50 years old, consistent with the menopausal age range of women. Decreased female hormones after menopause may be involved in the aetiology of BPPV [3].
Dynamic visual acuity in benign paroxysmal positional vertigo
Published in Acta Oto-Laryngologica, 2018
Freely floating otoconia inside the semicircular canals or those adhering to the cupula make the ampullary hair cells sensitive to gravitational forces in patients with benign paroxysmal positional vertigo (BPPV) who experience a sudden sense of vertigo when they turn their head to either side or when they bend their head forward or backward [1]. A brief and sudden positional nystagmus associated with change in head position relative to gravity may temporarily impair visual stability. Utricular degeneration leading to otoconial detachment is blamed to be as the source of traveling crystalloids. Vascular damage or ischemia of the utricle could be the underlying cause. Several authors claim that BPPV is not a disease but a syndrome and its an end-result of a possible organic pathology. Considerable findings supporting these remarks exist since BPPV can be associated with several inner ear pathologies. Sudden idiopathic neurosensorial hearing loss in some patients with BPPV may share common pathophysiological etiology [2]. Some patients have recurrence and have chronic instability even after successful repositioning maneuvers. More recently, it has been reported that BPPV is correlated with osteoporosis. It could be a ‘bone turn-over’ pathology since recurrences are less likely in patients with vitamin-D replacement therapy [3].
Related Knowledge Centers
- Inner Ear
- Vertigo
- Nausea
- Balance Disorder
- Labyrinthitis
- Ménière'S Disease
- Head Injury
- Otolith
- Dix–Hallpike Test
- Nystagmus