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Auris Nasus Larynx

Volume 44, Issue 1, February 2017, Pages 1-6
Auris Nasus Larynx

Classification, diagnostic criteria and management of benign paroxysmal positional vertigo

https://doi.org/10.1016/j.anl.2016.03.013Get rights and content

Abstract

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vertigo and the posterior and/or lateral semicircular canals are usually affected. BPPV is characterized by brief attacks of rotatory vertigo associated with positional and/or positioning nystagmus, which are elicited by specific head positions or changes in head position relative to gravity. In patients with the posterior-canal-type of BPPV, torsional nystagmus is induced by the Dix–Hallpike maneuver. In patients with the lateral-canal-type of BPPV, horizontal geotropic or apogeotropic nystagmus is induced by the supine roll test. The pathophysiology of BPPV is canalolithiasis comprising free-floating otoconial debris within the endolymph of a semicircular canal, or cupulolithiasis comprising otoconial debris adherent to the cupula. The observation of positional and/or positioning nystagmus is essential for the diagnosis of BPPV. BPPV is treated with the canalith repositioning procedure (CRP). Through a series of head position changes, the CRP moves otoconial debris from the affected semicircular canal to the utricle. In this review, we provide the classification, diagnostic criteria, and examinations for the diagnosis, and specific and non-specific treatments of BPPV in accordance with the Japanese practical guidelines on BPPV published by the Japan Society for Equilibrium Research.

Introduction

Robert Bárány first described positional vertigo in 1921 [1] and the term “benign paroxysmal positional vertigo” (BPPV) was coined by Dix and Hallpike in 1952 [2]. Currently, BPPV is the most common peripheral cause of vertigo. In most patients, BPPV is characterized by brief attacks of rotatory vertigo with torsional positioning nystagmus, which are elicited by changes in the head position relative to gravity. Because their posterior semicircular canal is affected, posterior-canal-type of BPPV is diagnosed. In 1985, McClure first reported lateral-canal-type of BPPV, in which the lateral semicircular canal was affected [3]. A direction-changing geotropic or apogeotropic positional nystagmus is elicited when the head of the patient, with lateral-canal-type of BPPV, is rolled from side to side on supine position.

Dix and Hallpike also suggested that BPPV was caused by a lesion of the otolith organ [2]. On postmortem examination of the temporal bones, Schuknecht then reasoned that the otoconia released from the otolithic membrane settled on the cupula (cupulolithiasis) and that the cupula would respond to gravity [4]. Hall et al. later hypothesized that the otoconial debris floats freely within the endolymph of the semicircular canal (canalolithiasis) [5]. Recently the canalolithiasis theory has drawn a lot of attention related to the canalith repositioning procedure (CRP) for the treatment of BPPV.

In this review, we provide the classification, diagnostic criteria, and examinations for diagnosis and specific and non-specific treatments of BPPV in accordance with the Japanese practical guidelines on BPPV published by the Japan Society for Equilibrium Research [6].

Section snippets

Diagnostic criteria for BPPV

Posterior-canal-type of BPPV (canalolithiasis)

  • A.

    Symptoms

    • 1.

      Attacks of rotatory vertigo or dizziness are induced by changes in the head position relative to gravity.

    • 2.

      The vertigo appears with short latency, lasts for less than a minute and is characterized by an increase followed by a decrease in its intensity.

    • 3.

      The intensity of the vertigo decreases or disappears after repeated head positioning.

    • 4.

      The vertigo is not associated with any cochlear symptoms such as hearing loss, tinnitus, or ear fullness.

    • 5.

      There

Examinations for the diagnosis of BPPV

Positional and/or positioning nystagmus should be observed with Frenzel's glasses or glasses equipped with an infrared CCD camera and the characteristics of evoked nystagmus, namely direction, amplitude, frequency, and torsional/vertical/horizontal components of the nystagmus are examined. The latency that elapses before the appearance of nystagmus and changes in the intensity of nystagmus thereafter is also examined.

In patients who suffer from cervical vertebral disease, the positional and/or

Characteristics of nystagmus associated with BPPV

  • i)

    Positioning nystagmus of the posterior-canal-type of BPPV

In patients with the right posterior-canal-type of BPPV, right torsional nystagmus (upper pole of the eye rotates to the right) is induced by the right Dix–Hallpike maneuver (Fig. 2A, left). The nystagmus often contains an additional vertical (upward) component. The nystagmus appears with short latency, lasts for less than a minute and is characterized by an increase followed by a decrease in its intensity. Torsional nystagmus, in which

Treatment for BPPV

  • i)

    The canalith repositioning procedure (CRP) and non-specific exercise

Patients with BPPV, the pathophysiology of which is assumed to be canalolithiasis, are treated with the CRP [8], [9], [10], [11]. Non-specific exercise is used regardless of the pathophysiology and affected canals.

  • 1)

    The Epley maneuver

Epley first reported the CRP in 1992 [9]. Thereafter, his method is called the Epley maneuver for the treatment of the posterior-canal-type of BPPV. The sequential head movements of the Epley

Conclusions

In this review, we have provided the classification, diagnostic criteria, the examinations for diagnosis, and specific and non-specific treatments of the posterior- and lateral-canal-type of BPPV in accordance with the Japanese practical guidelines on BPPV published by the Japan Society for Equilibrium Research [6].

Conflict of interest

None.

Acknowledgements

The members of Committee for Standards in Diagnosis of Japan Society for Equilibrium Research who edited part of the Japanese practical guidelines on BPPV, with the exception of the authors, are as follows: Prof. Masahiko Yamamoto, Dr. Setsuko Takemori, Dr. Tadashi Nakamura, Mr. Naofumi Tsuruoka, Dr. Motoyuki Hashiba, Dr. Takashi Fukaya, Prof. Kazuo Ishikawa, and Dr. Takao Yabe. The Japanese practical guidelines on BPPV that was published in Equilibrium Research 68: 218–225, 2009 in Japanese

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