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Rotate the head by 45° towards the affected side.Ask the patient to sit upright on the examination bed and to keep their eyes open during the procedure.Suspected anterior semicircular canal BPPV.Gold standard test to diagnose suspected posterior semicircular canal BPPV.If the Dix-Hallpike maneuver is negative, the supine head roll test should be performed to assess for lateral canal BPPV.The Dix-Hallpike maneuver should be performed in all patients with suspected BPPV to identify posterior canal BPPV.Fatigability: Intensity of nystagmus decreases on repeated sequential testing (not recommended).Reversal: The pattern of nystagmus reverses direction when the patient is made to sit in a neutral position at the end of the provoking maneuver.Duration: Direction: The direction of nystagmus indicates which specific canal is affected (see individual maneuvers below for more details).The following characteristics of nystagmus should be noted:.Findings: Positional vertigo associated with nystagmus triggered on specific maneuvers is considered a positive test and is diagnostic of BPPV.Definition: set of specific sequential maneuvers used to provoke symptoms in an individual with suspected BPPV.
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Elicitation of vertigo and nystagmus on performing Dix-Hallpike maneuver, with the following characteristics:.Episodic vertigo triggered by changes in head position in relation to gravity.Failure to respond to canalith repositioning maneuvers or vestibular rehabilitation therapy ĭiagnostic criteria for posterior semicircular canal BPPV Īll of the following criteria should be met to confirm the clinical diagnosis of posterior canal BPPV.Associated neurological symptoms (e.g., gait disturbances) are present.Vertigo that lasts longer than one minute.Consider other diagnoses if any of the following are present:.
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Patients with atypical features or suspected differential diagnoses: Consider further evaluation with audiometry, vestibular function testing, and/or neuroimaging as needed.BPPV is a clinical diagnosis based on characteristic findings and elicitation of nystagmus and vertigo on provoking maneuvers for BPPV.The following focuses on patients with triggered episodic vestibular syndrome see “ Approach to vertigo” for details on clinical evaluation, targeted testing (e.g., HINTS examination), and neuroimaging for patients with undifferentiated acute vestibular syndrome. Canalithiasis or cupulolithiasis → abnormal stimulation of the vestibulocochlear nerve in response to changes in head position and movement → severe vertigo attacks that last several seconds.Cupulolithiasis → increased sensitivity of the semicircular canal to changes in gravitational forces → abnormal stimulation of the vestibular apparatus.Cupulolithiasis: otoconial debris that has adhered to the cupula of the affected semicircular canal.Canalithiasis from the acoustic macula enter the semicircular canals → disruption of endolymph dynamics in response to changes in gravitational forces (e.g., changing head positions) → abnormal stimulation of the vestibular apparatus.Dislodged, free-floating otoconia (endolymphatic debris).Otoconia ( otoliths): physiological calcium carbonate crystals present within the utricle and saccule that serve to maintain balance and spatial orientation.Vestibular suppressants and surgery are reserved for patients with intractable or severely-disabling BPPV.Īlthough incompletely understood, BPPV is thought to occur due to dislodged or abnormally adherent otoconia, causing semicircular canal dysfunction. Vestibular rehabilitation may be used as an adjunct to ( CRM). Canalith repositioning maneuvers ( CRM), such as the Epley maneuver, are the preferred treatment of BPPV. BPPV is a clinical diagnosis that is supported by a combination of characteristic features as well as the presence of nystagmus and vertigo elicited by provoking maneuvers (e.g., Dix-Hallpike test). The primary symptom of BPPV is episodic vertigo that lasts < 1 minute, triggered by sudden changes in head posture in relation to gravity (e.g., bending forwards, rapidly standing up). BPPV is the most common cause of peripheral vertigo. Benign paroxysmal positional vertigo (BPPV) is a common disorder of the inner ear thought to be caused primarily by otoconia (canaliths) dislodging and migrating into one of the semicircular canals, most commonly the posterior semicircular canal, where it disrupts the endolymph dynamics.