Dizziness & Vertigo Treatment of benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is a peripheral vestibular disorder induced by changes in head position relative to gravity and manifested by recurrent transient vertigo and characteristic nystagmus, often self-limited and prone to recurrence
.

BPPV can be divided into posterior semicircular tube BPPV (PC-BPPV), horizontal semicircular tube BPPV (HC-BPPV), anterior semicircular tube BPPV (AC-BPPV) and mixed BPPV
according to the affected parts.
Among them, PC-BPPV is the most common, accounting for 70%~90%, followed by HC-BPPV, accounting for 10%~30%.

diagnosis

For the diagnosis of BPPV, it is necessary to reduce missed diagnoses and generalization
.

Reducing missed diagnosis of BPPV requires attention to the following:

1.
Atypical medical history

The typical history of BPPV is characterized by: (1) repeated transient dizziness when getting up and turning over in bed; (2) Transient dizziness (movements that change the direction of gravity such as bending over and raising the head)
in some specific movements.

Patients over 60 years of age with dizziness and unstable posture, especially those with a short medical history, whose characteristics are not typical, require a position test
.
Studies have reported that the incidence of BPPV is as high as 9%
in 100 elderly people with chronic diseases who do not have a complaint of dizziness in the community.

2.
Patients with negative location test

20% of patients with HC-BPPV have a negative nystagmus at the time of the Dix-hallpike test, so a roll test and other tests
as appropriate are necessary.

3.
False-negative patients on positional tests

The false-negative rate of the first position test has been reported to be as high as 19.
12%, so the first position test is negative, or the nystagmus characteristics are atypical, and the test can be repeated after shaking the head
.
If the patient develops symptoms the next day, the position test
should also be repeated.

The Guidelines for the Diagnosis and Treatment of BPPV (2017) introduce the concept of graded diagnosis, dividing patients with symptoms of positional vertigo into confirmative, probable, and controversial syndromes
.

Determine the diagnosis

1.
Recurrent, transient vertigo or dizziness
after changing the head position relative to the direction of gravity.

2.
Position test can induce vertigo and nystagmus, and the nystagmus characteristics are in line with the performance of the corresponding semicircular canal excitation or inhibition: (1) PC-BPPV: vertical jumping nystagmus with torsion component (vertical component up, twisting component down ear) occurs when the affected ear is facing the ground, the direction of the nystagmus is reversed when returning to the sitting position, and the duration of vertigo and nystagmus usually does not exceed 1 min; (2) HC-BPPV: Both bilateral position tests can induce horizontal ground or horizontal ground separation nystagmus.

3.
Exclude other diseases
.

Diagnosis possible

1.
Recurrent, transient vertigo or dizziness after changing the head position relative to the direction of gravity, usually lasting no more than 1 min
.

2.
The position test did not induce vertigo or nystagmus
.

3.
Exclude other diseases
.

Controversial syndrome

1.
Recurrent, transient vertigo or dizziness
after changing the head position relative to the direction of gravity.

2.
Positional nystagmus induced by the position test does not conform to the corresponding semicircular canal excitation or inhibition, is difficult to distinguish from central positional nystagmus, or has positional nystagmus in multiple position tests but cannot determine the responsibility of the semicircular canal, or has both peripheral and central positional nystagmus, or vertigo occurs in the position test but no nystagmus
is observed.

Studies have reported that of 121 patients with positive positional tests, only 49 were consistent with BPPV nystagmus, accounting for 40.
5%.

Analysis of these controversial syndromes is characteristic: frequent spontaneous nystagmus; nystagmus duration>1 min; weak nystagmus intensity; often accompanied by a history of headache; Often accompanied by a history of
motion sickness.

In addition, a clear risk factor for BPPV is migraine, and migraine-related positional vertigo is characterized by: medical history 2~3 days; Recurrent seizures; Age 30~40 years old; Continuous nystagmus at low frequency and low speed; No interchangeable nystagmus
.

treat

At present, clinical treatments for BPPV include otolith reduction, drug therapy, surgical treatment, and vestibular rehabilitation
.
Otolith reduction is currently the main method of treating BPPV, which is easy to operate and can be done by hand or with the help of instruments, with good
results.
When resetting, the corresponding method
should be selected according to different types.

PC-BPPV reset

1.
Homonystagmus occurs in multiple positions during the reset, indicating that the reset effect is better;

2.
Horizontal ground nystagmus is induced again, prompting entry into the horizontal semicircular canal - reset according to the horizontal pipe stone;

3.
Re-induce horizontal dorsal nystagmus for unknown reasons and does not affect the efficacy;

4.
A "falling feeling" may occur within a few hours after reposition, which may indicate that the otolith has entered the oval capsule and indicate that the reset is successful
.

HC-BPPV reset

1.
Lie flat on the eye tremor and turn over in the direction of the nystagmus: barbecue reset;

2.
Lie on the side where the nystagmus is weak and shake your head in the direction of the nystagmus: Gufoni reset;

3.
Forced lying position
on the healthy side.

AC-BPPV reset

Dix-Hallpike test: both sides can induce downward twisting of nystagmus in the direction of the lesion
.
The reset method can be reset by Yacovino or Li
.