Benign Positional Vertigo in Emergency Medicine
No Results
No Results
processing….
Benign positional vertigo (BPV), also known as benign paroxysmal positional vertigo (BPPV), is the most common cause of vertigo. Vertigo is an illusion of motion (an illusion is a misperception of a real stimulus) and represents a disorder of the vestibular proprioceptive system.
BPV was first described by Adler in 1897 and then by Bárány in 1922; however, Dix and Hallpike did not coin the term benign paroxysmal positional vertigo until 1952. This terminology defined the characteristics of the vertigo and introduced the classic provocative diagnostic test that is still used today. Using positional testing, benign positional vertigo can readily be diagnosed in the emergency department. Benign positional vertigo is one of the few neurologic entities the emergency physician can cure at the patient’s bedside by performing a series of simple and safe head-hanging maneuvers.
For further information, see Benign Positional Vertigo in the Neurology volume.
Benign positional vertigo (BPV) is caused by calcium carbonate particles called otoliths (or otoconia) that are inappropriately displaced into the semicircular canals of the vestibular labyrinth of the inner ear. These otoliths are normally attached to hair cells on a membrane inside the utricle and saccule. Because the otoliths are denser than the surrounding endolymph, changes in vertical head movement causes the otoliths to tilt the hair cells, which sends a signal informing the brain that the head is tilting up or down.
The utricle is connected to the 3 semicircular canals. The otoliths may become displaced from the utricle by aging, head trauma, or labyrinthine disease. When this occurs, the otoliths have the potential to enter the semicircular canals. When they do, they usually enter the posterior semicircular canal because this is the most dependent (inferior) of the 3 canals, and so gravitational forces will result in most otoliths entering the posterior canal.
According to the canalolithiasis theory (the most widely accepted theory describing the pathophysiology of benign positional vertigo), the otoliths are free-floating within the semicircular canal. Changing head position causes the misplaced otoliths to continue to move through the canal after head movement has stopped. As the otoliths move, endolymph moves along with them and this stimulates the hair cells of the cupula of the affected semicircular canal, sending a signal to the brain that the head is turning when it is not. This results in the sensation of vertigo. When the otoliths stop moving, the endolymph also stops moving and the hair cells return to their baseline position, thus terminating the vertigo and nystagmus. Reversing the head maneuver causes the particles to move in the opposite direction, producing nystagmus in the same axis but reversed in direction of rotation. The patient may describe that the room is now spinning in the opposite direction. When repeating the head maneuvers, the otoliths tend to become dispersed and thus are progressively less effective in producing the vertigo and nystagmus (hence, the concept of fatigability).
United States
The incidence of benign positional vertigo (BPV) is 64 cases per 100,000 population per year (conservative estimate). [1]
International
One study in Japan found an incidence of 11 cases per 100,000 population per year, but patients were counted only if examined by a subspecialist or at a referral center.
The B of BPV stands for benign and designates that the cause of the vertigo is peripheral to the brainstem and, hence, likely to be benign. However, BPV can be severely incapacitating to the patient.
Women are affected twice as often as men.
BPV, in general, is a disease of elderly persons, although onset can occur at any age. Several large studies show an average age of onset in the mid 50s. Vertigo in young patients is more likely to be caused by labyrinthitis (associated with hearing loss) or vestibular neuronitis (normal hearing).
Froehling DA, Silverstein MD, Mohr DN, Beatty CW, Offord KP, Ballard DJ. Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota. Mayo Clin Proc. 1991 Jun. 66(6):596-601. [Medline].
[Guideline] Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008 Nov. 139(5 Suppl 4):S47-81. [Medline]. [Full Text].
Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med. 1999 Nov 18. 341(21):1590-6. [Medline].
Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014 Dec 8. 12:CD003162. [Medline].
[Guideline] Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008 May 27. 70(22):2067-74. [Medline]. [Full Text].
Epley JM. Particle repositioning for benign paroxysmal positional vertigo. Otolaryngol Clin North Am. 1996 Apr. 29(2):323-31. [Medline].
Kim AS, Fullerton HJ, Johnston SC. Risk of vascular events in emergency department patients discharged home with diagnosis of dizziness or vertigo. Ann Emerg Med. 2011 Jan. 57(1):34-41. [Medline].
Baloh RW. Dizziness and vertigo. Samuels MA, Feske S. Office Practice of Neurology. London: Churchill Livingstone; 1996. 83-91.
Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol. 1980 Aug. 106(8):484-5. [Medline].
Chang AK, Schoeman G, Hill M. A randomized clinical trial to assess the efficacy of the Epley maneuver in the treatment of acute benign positional vertigo. Acad Emerg Med. 2004 Sep. 11(9):918-24. [Medline].
Froehling DA, Bowen JM, Mohr DN, et al. The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial. Mayo Clin Proc. 2000 Jul. 75(7):695-700. [Medline].
Kim JS, Zee DS. Clinical practice. Benign paroxysmal positional vertigo. N Engl J Med. 2014 Mar 20. 370(12):1138-47. [Medline].
Lempert T, Gresty MA, Bronstein AM. Benign positional vertigo: recognition and treatment. BMJ. 1995 Aug 19. 311(7003):489-91. [Medline].
Marill KA, Walsh MJ, Nelson BK. Intravenous Lorazepam versus dimenhydrinate for treatment of vertigo in the emergency department: a randomized clinical trial. Ann Emerg Med. 2000 Oct. 36(4):310-9. [Medline].
Massoud EA, Ireland DJ. Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. J Otolaryngol. 1996 Apr. 25(2):121-5. [Medline].
Troost BT, Patton JM. Exercise therapy for positional vertigo. Neurology. 1992 Aug. 42(8):1441-4. [Medline].
Andrew K Chang, MD, MS Vincent P Verdile, MD, Endowed Chair in Emergency Medicine, Professor of Emergency Medicine, Vice Chair of Research and Academic Affairs, Albany Medical College; Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Emergency Medicine, Montefiore Medical Center
Andrew K Chang, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American Academy of Pain Medicine, American College of Emergency Physicians, American Geriatrics Society, American Pain Society, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
J Stephen Huff, MD, FACEP Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine
J Stephen Huff, MD, FACEP is a member of the following medical societies: American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Liudvikas Jagminas, MD, FACEP Chief of Service, Attending Physician, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Vice-Chair for Network Development, Department of Emergency Medicine, Beth Israel Deaconess and Harvard Medical Faculty Physicians; Adjunct Associate Professor of Emergency Medicine, The Warren Alpert Medical School of Brown University
Liudvikas Jagminas, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, International Trauma Anesthesia and Critical Care Society, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Edward Bessman, MD, MBA Chairman and Clinical Director, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine
Edward Bessman, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Robert E O’Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System
Robert E O’Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Heart Association, American Medical Association, National Association of EMS Physicians, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Benign Positional Vertigo in Emergency Medicine
Research & References of Benign Positional Vertigo in Emergency Medicine|A&C Accounting And Tax Services
Source
0 Comments